Referring dentist

Referred by
Referral for
Reason for referral  Consultation Root Canal Therapy Periapical Surgery Other
Additional diagnostic information  Mild sensitivity to cold and/or hot Severe sensitivity to cold and/or hot Severe pain Swelling Non-specific pain for diagnosis Pain to biting and/or pressure sensitivity Elective endodontics Retreatment
Patient name
Patient telephone number
Endodontic Consideration of the Following Teeth:
Right Left
Top - RightTop - Left
Bottom - RightBottom - Left
Post Space Required?  Yes No
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Check the anti-bot field
Check the anti-bot field