Endodontic Excellence - Secure Online Referral

ALAN WONHEE LEE, DDS, MS

Please correct the errors described below.

Practice Limited to Endodontics, Enhanced by Laser and Microspoce

11800 Sunrise Valley Dr., Suite 250 Reston VA 20191

(703) 429-9926
info@endoreston.com
www.endoreston.com

PATIENT INTRODUCTION AND REFERRAL

Patient's Name:

Tooth/Teeth Area:

From Doctor:

Office Phone:

Call Referring Doctor Prior to Consultation/Treatment

Send Referral Pads

REASON FOR REFERRAL

Consultation Only

Provide Treatment as Needed

CBCT Only

Specify here:

Other

Specify here:

TREATMENT REQUESTED

Root Canal Therapy

Retreatment or Apicoectomy

Resporption

Vital Pulp Therapy

Regenerative Endodontics

Dental Trauma

Internal Bleaching

BOTOX® for Bruxism

Crack or Fracture

Laser Photobiomodulation Therapy

Please Specify:

Other

Please Specify:

RESTORATIVE CONSIDERATIONS

Restore Access with Permanent Material

Crown Lengthening

Post Space Preperation

Other

Please Specify:

PATIENT HAS BEEN PUT ON

Antibiotics:

Please Specify:

Pain Medication:

Please Specify:

ADDITIONAL REMARKS:

Your information will be encrypted.

Practice Limited to Endodontics, Enhanced by Laser and Microspoce

11800 Sunrise Valley Dr., Suite 250 Reston VA 20191

(703) 429-9926
info@endoreston.com
www.endoreston.com

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide