Referring Doctors

    Referred By (required)

    Referral for (required)

    Patient name

    Patient telephone number

    Date of Birth

    Appointment Date

    Please call Patient:
    YesNo

    Have we seen the patient before:
    YesNo

    Please Mark Tooth To Be Treated::

    RIGHT 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 LEFT
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

    Reason for referral
    ConsultationRoot Canal TherapyPeriapical SurgeryIV sedation

    Additional diagnostic Information
    Mild sensitivity to cold and /or hotSevere sensitivity to cold and /or hotSevere pain and/or swellingNon-specific pain for diagnosisPain to biting and/or pressure sensitivityElective endodonticsRetreatment

    Additional Comments/Remarks:

    Post Space Required?
    YesNo

    Premedication Antibiotic Required:
    YesNo

    Referring dentist email address:(required)

    Radiographs:
    Digital film AttachedPatient to BringNo Radiograph

    Upload X-ray (optional)

    Upload X-ray (optional)

    Upload X-ray (optional)

    Upload X-ray (optional)

    Secure SSL Certificate