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Endodontic and Implant Referral Form

Endodontic consult and treat as necessary
Implant
Endodontic retreatment/surgery
Treat for restorative reasons (intentional endodontics)
IV sedation (driver needed, NPO 8hrs before)
Permament Teeth
Upper Right
Upper Left
Lower Right
Lower Left
Toothache
Pain and swelling
Sinus tract
Bite tenderness
Pain of unknown origin
Temporary
Permanent restoration
(composite core)
Post space
Post and core

Please give 48 hours notice if you cannot make your appointment