Referring Doctors Patient's Name Phone Number For tooth # Patient is being referred for the following: DiagnosisRoot Canal TreatmentRetreatmentEndodontic Surgery Additional Information: Pulp was exposedRCT begunPeriapical radiolucencyAsymptomaticTooth has crownTooth has fractureLeave post spaceSBE prophylaxis requiredPre-prosthetic endodontics required Please call me concerning patient Tooth is treatment planned for Appointment Scheduled for: Date: Time:
