PLEASE LET US KNOW
Referring Dentist: Dr.
Referring Office Contact Information
Patient Name
Patient Phone
Patient Email
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
Consultation and Treatment
CBCT only
Retreatment
Has RCT already been started? if yes, when?
Emailed
Antibiotics; Please list
No x-rays
Pain Medication; Please list
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None
Moderate
Cold Sensitivity
Biting/Pressure Sensitivity
Throbbing pain
Mild
Severe
Hot Sensititvity
Facial Swelling
Additional Comments