Referral - California

REFERRAL SLIP
DATE*

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

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

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

Endodontics necessary for proper restorationPost SpacePulp 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: