SECURE ONLINE REFERRAL
PATIENT INTRODUCTION AND REFERRAL
Patient's Name
Please call Patient to schedule
Patient's Prefered Name
Patient's #
Date of Birth
Tooth/Teeth Area:
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5
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25
26
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31
32
From Doctor:
Referral Date:
Office Phone:
Tooth/area in question has been previously evaluated/treated at Greensboro Endodontics (Beavers & Keating DDS, PA)
Call Referring Doctor Prior to Consultation/Treatment
Send More Referral Pads
REASON FOR REFERRAL
Consultation Only
Evaluate & Treat as needed
CBCT Only
Other
TREATMENT REQUESTED
Root Canal Therapy
Retreatment or Apicoectomy
Resorption evaluation/repair
Vital Pulp Therapy
Dental Trauma
Crack or Fracture
Internal Bleaching
Other
WHAT IS THE RESTORATIVE PLAN?
RESTORATIVE REQUEST:
Teflon and Cavit (Default)
Core Build-up
Access patch filling
Prepare Post Space
Place Post and Core
Remove Existing Crown
Evaluate Restorability
Gingivectomy/Crown Lengthening
Other
PATIENT HAS BEEN PUT ON
Antibiotics:
Pain Medication:
Additional Remarks:
Upload X-rays (Optional)