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
Referring Doctor/Office (First and Last Name, please):
*
Patient Phone:
*
Patient Email:
example@example.com
Appointment Date:
/
Month
/
Day
Year
Date
Time:
Hour Minutes
AM
PM
AM/PM Option
Office Phone:
*
Referring Office Email (for report):
*
Dental Insurance (If applicable, please include carrier, ID#, Subscriber Name and DOB):
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 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
Root Canal Therapy could not be completed due to (provide info in remarks):
Suspected Cracked Tooth or Root Fracture
Other
When treatment is complete:
Place permanent restoration
Place a temporary 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
Anything else we should know?
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