REFERRING DENTISTS

Patient's Name: Appointment Date:

Phone ###-###-####: Time:

History

Patient has discomfort / pain
Resent Dental Treatment
Apical Radiolucency
Swelling
Fracture
Traumatic Injury
Previous Root Canal Treatment
Allergies
ODSP/OW/HSO

Treatment to be completed at Willowdale Endodontics:

Please Provide Consultation / Diagnosis
Please Provide Root Canal Therapy
Please Provide an Evaluation for Possible Endodontic Retreatment or Apical Surgery
Please Leave a Post Space
Please Consider Non-Vital Bleaching
Nitrous Oxide Sedation Required
Oralmoderate

Treatment Administered Prior to Referral:

Occlusal Adjustment
Endodontic Therapy has Been Initiated
Incision & Drainage
Premed Required
Crown/Bridge is Cemented - Temporarily
Crown/Bridge is Cemented - Permanently
Rx Antibiotic
None
CBCT Scan: Reason: QUAD: Pan Ceph:

Referred by Dr: Dr.'s E-mail:

Date: Select Location:

Additional Notes:

Upload X-Ray?

(File Types: PDF,jpeg,jpg,png,gif,bmp | Max. File Size: 3Mb)

Select File #1

Select File #2

Select File #3

Select File #4

Select File #5

Right	1	8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8	2	Left
Right	4	8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8	3	Left

Specialty Endodontics by Dr. Rita

Online Referral Form

History

Treatment to be completed at Willowdale Endodontics:

Treatment Administered Prior to Referral:

Request An Appointment