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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