Referred by Please leave this field empty. Referral for Dr. José Line Leduc Reason for referral ConsultationRoot Canal TherapyPeriapical SurgeryOther Additional diagnostic information Mild sensitivity to cold and/or hotSevere sensitivity to cold and/or hotSevere painSwellingNon-specific pain for diagnosisPain to biting and/or pressure sensitivityElective endodonticsRetreatment Patient name Patient telephone number Endodontic Consideration of the Following Teeth: Right Left Top - Right1817161514131211Top - Left2122232425262728 Bottom - Right4847464544434241Bottom - Left3132333435363738 Post Space Required? YesNo Comments Your E-mail Address Upload X-ray (optional) Upload X-ray (optional) Upload X-ray (optional) Upload X-ray (optional) Upload X-ray (optional)