Doctor Referral Form Upper Leslie Endodontics Please enable JavaScript in your browser to complete this form.Patient's Name *Tooth in Question *8 7 6 5 4 3 2 1 2 3 4 5 6 7 8 ------------------|----------------- 8 7 6 5 4 3 2 1 2 3 4 5 6 7 8HistoryPainApical RadiolucencyFracturePeriodontal ConditionPlup ExposureTraumaTreatment Administered Prior to Referral:Occlusion Adjusted Sedative Dressing PlacedPulpotomy / Pulpectomy Incision / Drainage Rx Antibiotic Prior RootCanalTreatment to be Completed in the Endodontic OfficeConsultation / DiagnosisElective (Prophylactic) Endodontic TherapyEvaluation and Treat Endodontic SurgeryCreate Post Space Close Access with Temporary FillingClose Access With Permanent FillingCommentsReferring Doctor *Dr Office Contact info *Submit We can take away the pain, No need to take away your teeth (905) 235 1101
