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Referral Form – Endodontics
Office:
Date:
Patient Name:
Referring Doctor:
Treatement To Be Performed:
Consultation Only
Periapical radiolucency present
Pulp exposure
RCT required for proper restoration
Evaluation for endodontic surgery
Root canal therapy
Restorative Instructions:
Place post and build-up
Leave post space
Place temp in access cavity
Place final restoration in access cavity
Restorative Instructions:
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32
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Miscellaneous:
Call me about this case
Crown and bridge is cemented
Temporarily
Permanently
Special Instructions:
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