Endodontics Referrals

Referring Dentist Details

Address

Patient Details

DD slash MM slash YYYY
Address

TOOTH/AREA TO BE TREATED (select all that apply – if relevant):

TOOTH/AREA TO BE TREATED (select all that apply – if relevant):
Radiographs
(include any special factors – either dental or medical – such as allergies and specific medical problems relevant to diagnosis and treatment)
Post-operative Restoration
ARE YOU HAPPY FOR ALTERNATIVE TREATMENT OPTIONS TO BE OFFERRED IF ROOT CANAL TREATMENT IS NOT POSSIBLE?