Patient Referral Form

Northshore Endodontics, 5701 NE Bothell Way, Kenmore, WA 98028

Phone: 425-488-9785, Fax: 425-402-0835, E-mail: info@northshore-endo.com

Download printable referral form, or complete online version below.

Introducing    Date
Home Phone    Work Phone

Referring Dr    Phone

Patient is appointed for at
Please contact patient for appointment
Patient will contact your office

Tooth/area to be evaluated

History (please check)
Spontaneous pain
Hot sensitivity
Cold sensitivity
Pulp exposure
Chewing sensitivity
Trauma
Previous endodontic treatment
Periapical radiolucency
Endodontics started
Other
Date or duration of checked

Rx antibitioc Started on
Rx pain meds Started on

Treatment requested
Consultation only
Examine and treat as needed
Call prior to starting treatment
Prepare canal with post space (size will be kept conservative)
Other

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