Referral form
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Date:
Patient Name:
Referring Doctor:
Treatement To Be Performed:
Consultation OnlyPeriapical radiolucency presentPulp exposureRCT required for proper restorationEvaluation for endodontic surgeryRoot canal therapy
Restorative Instructions:
Place post and build-upLeave post spacePulp exposurePlace temp in access cavityPlace final restoration in access cavity
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Miscellaneous:
Call me about this caseCrown and bridge is cementedTemporarilyPermanently
Special Instructions:
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