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Endodontic Referral Form

Patient Details

Title..: Name: Address: Postcode: Date of Birth: Telephone (Day): Telephone (Eve): Mobile: Email: Is this referral urgent? Tooth / teeth to be treated:

Reason For Referral (Please select relevant options)

Abutment for bridge/new crown: Existing post/post removal: Difficult access: Broken instrument: Opinion only: Endodontic treatment: Non-visible/sclerosed canals: Difficult tooth morphology (curved canals): Other reason and/or relevant information:

INVESTIGATIONS

Relevant Medical History:

TREATMENT HISTORY

Treatment attempted Pre-operative radiograph enclosed

RADIOGRAPHS INCLUDED

Attach Radiograph: Attach Radiograph: Attach Radiograph: Bite Wings Peri-Apical OPT

Referring Dentist Details (Please ensure this section is fully completed)

Referring Practitioner: Practice Name: Address: Postcode: Date of Referral: Telephone: Email:

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