PLEASE LET US KNOW

Referral Form

Tooth/Area of Concern

  • 8RT8
  • 7RT7
  • 6RT6
  • 5RT5
  • 4RT4
  • 3RT3
  • 2RT2
  • 1RT1
  • 1LT1
  • 2LT2
  • 3LT3
  • 4LT4
  • 5LT5
  • 6LT6
  • 7LT7
  • 8LT8
  • 8RB8
  • 7RB7
  • 6RB6
  • 5RB5
  • 4RB4
  • 3RB3
  • 2RB2
  • 1RB1
  • 1LB1
  • 2LB2
  • 3LB3
  • 4LB4
  • 5LB5
  • 6LB6
  • 7LB7
  • 8LB8

Referral Request

Consultation and Treatment
CBCT only
Retreatment

An X-ray is being

Patient has been put on

Emailed
Antibiotics; Please list
No x-rays
Pain Medication; Please list

Level of Discomfort

None
Moderate
Cold Sensitivity
Biting/Pressure Sensitivity
Throbbing pain
Mild
Severe
Hot Sensititvity
Facial Swelling