Endodontic Excellence - Secure Online Referral

ALAN WONHEE LEE, DDS, MS, AND STEVEN KIM, DMD

Please correct the errors described below.

Practice Limited to Endodontics, Enhanced by Laser, Gentlewave, and Microscope

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:

Referral Date

Office Phone:

Call Referring Doctor Prior to Consultation/Treatment

Send More 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

Crack or Fracture

BOTOX® for Bruxism

Internal Bleaching

GentleWave® Procedure

Please Specify:

Other

Please Specify:

WHAT IS THE RESTORATIVE PLAN?

Please Specify:

RESTORATIVE CONSIDERATIONS

Teflon and Cavit (Default)

Core Build-up

Post Space Preperation

Remove Existing Crown

Evaluate Restorability

Crown Lengthening

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, Gentlewave, and Microscope

11800 Sunrise Valley Dr., Suite 250 Reston VA 20191

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

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