SECURE ONLINE REFERRAL
PATIENT INTRODUCTION AND REFERRAL
Patient's Name
Please call Patient to schedule
Patient's Prefered Name
Patient's Phone #
Date of Birth
Tooth/Teeth Area:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
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
PREVISIT INSTRUCTIONS: Please complete New Patient Registration at www.endotriadnc.com *** If possible, please refrain from taking Ibuprofen (Advil) or Naproxen (Aleve) for 8 hours prior to your appointment
Additional Remarks:
Upload X-rays (Optional)