Referral - Greenbelt

REFERRAL SLIP
DATE *

Month Day Year
Date
INTRODUCING THE FOLLOWING PATIENT FOR ENDODONTIC CONSIDERATION. PATIENT WILL BE RETURNED TO REFERRING DENTIST FOR FINAL RESTORATION.
PATIENT NAME *

First Name Last Name
REMARKS *
REFERRED BY *
PHONE NUMBER OF REFERRING DOCTOR *

Area Code Phone Number
TEETH FOR CONSIDERATION *
TO BE FILLED IN BY DENTIST *

Endodontics necessary for proper restoration Post Space Pulp was exposed and was vital. Pulp was exposed and was non-vital. Pulp was exposed and status of pulp couldn't be determined absolutely. Tooth is open for drainage. X-Ray revealed pulpal involvement. X-Ray revealed radiolucency. Patient has vague toothache, please evaluate. Patient has pain, swelling or sensitivity, please evaluate.
Other
Should be Empty:

REFERRAL SLIP