Date Referred:
*
/
Month
/
Day
Year
Date
Scheduling Preference:
Reach out to patient to schedule
Patient will reach out to schedule
Patient Name:
*
Date of Birth:
*
/
Month
/
Day
Year
Date
Patient Phone:
*
Patient Email:
example@example.com
Referring Doctor/Office (First and Last Name, please):
*
Referring Office Phone:
*
Format: (000) 000-0000.
Referring Office Email (for report):
*
Appointment Date:
/
Month
/
Day
Year
Date
Time:
Hour Minutes
AM
PM
AM/PM Option
Dental Insurance (Please include Carrier, Subscriber Name, DOB, and ID Number):
Select teeth/area to be evaluated:
UR
LR
UL
LL
1
17
2
18
3
19
4
20
5
21
6
22
7
23
8
24
9
25
10
26
11
27
12
28
13
29
14
30
15
31
16
32
Other
Patient is being referred for consultation for the following:
Root Canal Therapy
Retreatment
Endodontic Surgery
Sedation (Oral, Nitrous)
3D Scan (no consult)
Patient presents with the following:
Diffuse Pain
Swelling
Sensitivity to HEAT
Sensitivity to COLD
Sensitivity to PRESSURE
Draining Sinus Tract
Trauma
Calcified Canals
Periapical Lesion
Suspected Cracked Tooth or Root Fracture
Resorption Defect
RCT initiated but could not be completed due to (provide detail in remarks)
Pulpotomy/Pulpectomy completed
When treatment is complete, the treated tooth will be temporized, unless otherwise specified:
Place permanent restoration
Place post and core build-up
Prepare a post space
Clinical Remarks (Please include tooth's treatment history, if applicable):
Radiograph Attachment #1 (PA appreciated):
Image #1 date:
*
/
Month
/
Day
Year
Date
Radiograph Attachment #2 (PA appreciated):
Image #2 date:
*
/
Month
/
Day
Year
Date
If the referring provider prefers to discuss case with Dr. Lambert, please indicate:
Before exam
After exam
Anything else we should know?
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