Referring a Patient

For Doctors


Patient's Name
Patient's Phone
Insurance Info
Referred By
Office Phone
Office Email
Appointment Date

Choose Location

Vancouver Coquitlam

Tooth/Area of Concern

8 7 6 5 4 3 2 1
YOUR LEFT/PATIENT'S RIGHT
8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8
YOUR RIGHT/PATIENT'S LEFT
1 2 3 4 5 6 7 8

Reason for Referral

Consult Consult and Treat Call to Discuss

Tooth Status

RCT started, please complete.
Tooth has a post Tooth has temporary Crown
Tooth has a fixed prothesis
Permanent Cement Temporary Cement

After RCT

Restore access with permanent filling,
amalgam resin
Restore access with temporary filling.
Leave post space Place post

Attachments

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Remarks
 
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604-464-0411.

Evergreen Endo Group

Coquitlam & Vancouver [CONTACT]

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