APEX ENDODONTICS & IMPLANTOLOGY SPECIALISTS

Patient's Name

Tooth Number

Phone Number

Please enter a valid phone number.

DOB

Date

Referred By

Referring Doctor's Email

example@example.com

Please Call PatientOriginal X-ray Emailed

Services already performed

Tooth has been opened, medicated, and sealedPatient has been placed on an antibiotic and/or analgesic

Endodontic Services Requested

Consultation onlyEvaluate & treat as indicatedEvaluate for surgery or retreatmentLeave post spaceDo post & core build upThis tooth has had previous root canal treatmentCandidate for sedation (patient will require initial consult prior to treatment.)

Implant Services Requested

Evaluate for implantEvaluate for extraction/graft

Any other details or comments on the procedure

IT IS MY INTENTION TO RESTORE THE INVOLVED TOOTH WITH

Dowel postCompositeCrownOther

Date

Time

Hour Minutes

AM/PM Option

Doctor Name

HOW TO REACH US?

From,

HWY 280: Take Saratoga Ave South towards Saratoga, turn left on Cox Ave
HWY 85: Take Saratoga Ave North towards San Jose, turn right on Cox Ave
HWY 17: Take HWY 85 towards Mountain View, exit Saratoga Ave North
towards San Jose, then turn right on Cox Ave
Saratoga-Sunnyvale Road: Turn East on Cox Ave, cross Saratoga Ave
Quito Road: Turn on Cox Ave towards Quito Shopping Center (Small Sign)
Once on Cox Ave, turn into parking lot across from Quito Shopping
Center, enter through back doors into 18805 Cox Ave, located at the
corner of Cox and Paseo Presada.

APEX ENDODONTICS & IMPLANTOLOGY SPECIALISTS

Appointment