Endodontic Referral Form

Patient introduction and referral.

Referred by Dr:

Date:

Patient name:

Phone:

Reason for referral:

Tooth numbers:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Medications prescribed:

Pre-medicate
Oral/IV bisphosphonates
Blood thinners

Additional medications:

Chief complaints:

Cold sensitivity
Hot sensitivity
Spontaneous pain
Pain when chewing
Swelling
Recent dental treatments
Hx of bruxism or clenching
Limited jaw opening
Anxiety issues

Will crown be remade:

Fill chamber with:

Additional remarks:

Please Note: I do not offer endodontic retreatments and apical surgeries at this point. Please send us X-rays along with these filled referral forms for consultations and treatments. Patients will be promptly referred back to your office for definitive restoration/maintenance.

Office Email:

Office Phone:

Office Address:

Street Address City State / Province / Region

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Navigate

Services

Contact

Review Us