Patient Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Patient Phone *

(###)

###

####

Subscriber DOB (optional)

MM

DD

YYYY

Patient is being referred for the following: *

Evaluation Only

Root Canal Therapy (includes evaluation)

Retreatment/Apical Surgery (includes evaluation)

Sedation needed (Nitrous, oral, IV)

CBCT Only (No evaluation)

When treatment is complete: *

Place a temporary

Place a composite

Place an amalgam

Place a post and core buildup

Leave post space

Return for crown

History (check if present): *

Pulp exposure

Endodontic treatment initiated

Previously treated

Resorption (internal or external)

Deep probing (6mm or greater)

PT on blood thinner

Severe medically compromised/dementia

None of the above