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Referral Forms

Endodontics Referral Form

Referring Doctor

Referring Doctor Phone Number

Referring Doctor Email

Patient's Name

Patient's Phone Number

Patient's Email

Patient's Medical History

Tentative Diagnosis

Pain

Patient has discomfort/pain Traumatic injury Pulp exposed and necrotic material present Pulp is exposed and bleeding Tooth is open for drainage Radiograph enclosed Antibiotic prescribed Analgesic prescribed

Crown/Bridge is cemented

Temp-Perm

Temporarily Permanently

Prepare post space

Yes-No

Yes No

Sedation

Sedation General Anesthesia None

Radiographs

Uploaded Below Mailed Emailed Given to the Patient Please Take

Please upload radiographs (pan, ceph or other), if available (You can upload up to 10 files)

Upper Jaw

8 7 6 5 4 3 2 1

1 2 3 4 5 6 7 8

Lower Jaw

8 7 6 5 4 3 2 1

1 2 3 4 5 6 7 8

Note

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