Online Referral Form

*Implant Referral

Endodontic Referral

Title

First Name(s)

*Surname

Patients Address

Post Code

Date of Birth

Home Tel No.

Mobile

Work Tel No.

Email

*Referrring Dentist

Practice Tel No.

*Practice Email

Date of Referral

Practice Address

Post Code

Medical History

Medication being taken
(none dental usage)

For the evaluation/treatment of:

Tooth history:

Traumatic injury   Date of injury: / /

Previous Endodontic Therapy   Date of therapy: / /

Prosthesis is cemented permanently / temporarily

Radiographs enclosed

Alternative treatment options discussed

The patient has been prescribed the following:

Bond Core

Place Post

Post space required

Complete all restoration work

As endodontist, our responsibility is to ensure all root fillings are sealed against coronal leakage. As a minimum we will seal the canal orifices.
Time taken for core replacement can be unpredictable. In compromised / difficult clinical situations, a further appointment may be required
with an associate additional fee.

Is there any further information you think may be important with regard to the treatment of this patient or tooth?