Referral!form For Endodontic Treatment

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University!of!Pittsburgh!School!of!Dental!Medicine!
Department!of!Endodontics!
Referral!Form!for!Endodontic!Treatment!
!
This%page%is%to%be%completed%ONLY%by%the%referring%dentist.%%Please%FAX%to%our%office:%412C383C9478%
Patient Name:________________________________________ Phone:_________________________________
Referring dentist information:
Name of practice: ______________________________________________________________________
Referring dentist: ______________________________________________________________________
Phone number: ________________________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Information relative to treatment:
Area/tooth of concern: __________________________________________________________________
Proposed restorative treatment for this area: _________________________________________________
____________________________________________________________________________________
Recent/relative dental history pertaining to chief complaint: ____________________________________
____________________________________________________________________________________
Please check treatment requested:
__ Address chief complaint and treat as necessary
__ Evaluate for endodontic retreatment
__ Evaluate for apical surgery
__ Elective endodontics. All restorative and periodontal therapy will be addressed in the referring practice
__ Patient is to remain at the School of Dental Medicine for all remaining dental care
Referring dentist signature: _____________________________
Date: __________________
!!!
!
!
3501 Terrace Street, Pittsburgh, PA., 15261-4024
Phone: 412-648-8616 | FAX: 412-383-9478
!

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