DENTIST REFERRAL FORM

Please correct the errors described below.

Image

Patient Name

Patient Number

Appointment Date

Time

Upper

Right Side (Upper)

1

2

3

4

5

6

7

8

Left Side (Upper)

09

10

11

12

13

14

15

16

Lower

Right Side (Lower)

32

31

30

29

28

27

26

25

Left Side (Lower)

24

23

22

21

20

19

18

17

Remarks

Referring Doctor

Office Number

Date

Referring Requests

Consult and Treat as Necessary

Root Canal Treatment

Root Canal Retreatment

Apicoectomy

Assist with Diagnosis

Requested Restoration:

Post Space

Restore Access

Post Buildup

Other (Comment Below)

Requested Restoration Comments:

Dental History

Pain

Generalized Pain

Pulp Exposure

Trauma

Previously Opened

Possible Root Fracture / Crack

Apical Pathology

Other / Remarks (Comment Below)

Generalized Pain Type

UR LR UL LL

Dental History Comments:

3-D CBCT Imaging:

Maxillary Arch:

Tooth #:

Mandibular Arch:

Tooth #:

Panorex

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