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• Endodontic Treatment Referral Form

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• Date
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• Patient Name*
• Phone*

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• Referring Dentist*
• Phone*

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• Fax*

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• Special Instructions*
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• Upper Molars Select Molar 1 Molar 2 Molar 3 Molar 14 Molar 15 Molar 16
• Lower Molars Select Molar 32 Molar 31 Molar 30 Molar 19 Molar 18 Molar 17
• Upper Bicuspids Select Bicuspid 4 Bicuspid 5 Bicuspid 12 Bicuspid 13
• Lower Bicuspids Select Bicuspid 29 Bicuspid 28 Bicuspid 21 Bicuspid 20
• Upper Anteriors Select Anterior 6 Anterior 7 Anterior 8 Anterior 9 Anterior 10 Anterior 11
• Lower Anteriors Select Anterior 27 Anterior 26 Anterior 25 Anterior 24 Anterior 23 Anterior 22
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• Treatment Requested

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• Treatment*

  Evaluation Only Evaluation and Treatment 3D Radiograph
• Reason for Referral*

  Patient has pain and/or swelling Pulp is exposed Trauma Root canal treatment initiated Confirm possible retreatment or apical surgery Prepare post space Xray reveals extensive decay, ridiolucency or resorption
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