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Referral
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Referral Form
"
*
" indicates required fields
Date
*
MM slash DD slash YYYY
Referring Doctor
*
Office Email
*
Patient Name
*
Phone No/Cell
*
Tooth to be Evaluated
Reason for Referral
Consultation only
Periapical radiolucency present
Pulp exposure
RCT required for proper restoration
Evaluation for ReTx/ endodontic surgery
Tooth history includes crack/fracture
Initial testing indicates RCT necessary
Patient has vague toothache, please evaluate
Restorative Instructions
Place final restoration in access cavity
Place Cavit/IRM temp in access only
Leave post space
Do not place orifice barrier
Crown/bridge in cemented - Temporarily
Crown/bridge in cemented - Permanently
Anything Prescribed
Radiographs
Are current and labelled
X RAYS SEND VIA
Oral sedation may be needed?
Yes
No
Patient has dental benefits?
Yes
No
Patient's Preferred Appointment Day & Time
Any relevant medical condition of significance (Allergies/Premed)
Call to discuss with the referring dentist?
Yes
No
If yes, please provide contact no.
Special Instructions/Comment
