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Patient Referral
This will introduce
:
(First Name)
Date of Birth:
/
/
(Last Name)
Insurance Provider Certificate No.:
(mm/dd/yyyy)
Home Telephone: (
)
-
Work Telephone: (
)
-
x
Policy Number:
For evaluation of:
1
2
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
Right
Left
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
4
3
Referred by:
Dr.
Telephone: (
)
-
x
(First Name)
(Last Name)
Fax:(
)
-
x
E-mail:
Patient's Chief Complaint:
Onset:
Duration:
Intensity:
Dental History:
recent restoration
Date placed:
/
/
(mm/dd/yyyy)
composite resin
full coverage restoration
amalgam
other:
restoration / prosthesis of long-standing
traumatic injury
Date:
/
/
(mm/dd/yyyy)
previous endodontic therapy
Patient may also require:
periodontal therapy
orthodontics
oral surgery
Medical History:
Medications being taken (non-dental usage)
:
Patient has been advised that the following treatment may be required:
emergency therapy
non-surgical root canal therapy
retreatment
microsurgical root canal therapy
apexification
other
Information:
prosthesis is cemented
temporarily
permanently
radiographs enclosed of tooth
prior to tx
after completion
patient has been advised of guarded prognosis
alternative treatment options discussed
please call to discuss case prior to seeing patient
please call to discuss case after seeing patient
patient has been prescribed the following medications:
analgesic:
NSAID:
antibiotic:
Patient Concerns:
apprehension
time loss
insurance coverage
Please Discuss Sedation With Patient:
N2O2
Oral
IV
GA
Restorative Considerations:
no post space required
post space required
System:
Additional Comments: