Patient Name:
Date of Birth:
/
Month
/
Day
Year
Date
Phone #:
Referring Doctor/Office:
Appointment Date
-
Month
-
Day
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Select teeth 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 the following:
Consultation
Root Canal Therapy
Retreatment
3D Scan
Endodontic Surgery
Sedation (Oral, Nitrous, IV Sedation)
Other
Patient presents with the following conditions:
Diffuse Pain
Periapical Lesion
Swelling or Sinus Tract
Resorption Defect
Trauma
Pulpotomy/Pulpectomy completed
Suspected Cracked Tooth or Root Fracture
Other
Root Canal Therapy could not be completed due to:
N/A
Other
When treatment is complete:
Place permanent restoration
Place a temporary restoration
Place post and core build-up
Prepare a post space
Remarks:
Radiograph Attachment #1:
Radiograph Attachment #2:
Preview PDF
Submit
Should be Empty: