Patient Referral | Endodontic Solutions

Patient Details

Title

First Name*

Last Name*

Gender

Date Of Birth

Address

Preferred Contact Number

Clinical details Please click a tooth number below and enter the details for each tooth or type your own referral reason in the box below.

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Relevant medical history

Clinical details Please advise us the reason for referral with as much information as possible to assist your patient care. Reason for referral: Endodontic treatmentDiagnosisManagement of traumaSecond opinion

Additional Information

Pre-operative signs & symptoms

Current Status

Endodontic treatment required but not commenced This tooth has been accessed and medicated This tooth has previous endodontic treatment Pain requiring diagnosis and management Management of trauma

Restorative Requirements

Post endodontic restorative treatment has been discussed with patient Refer back for final restoration Temporary filling only Restore access as needed

Post Space YesNoat endodontist’s discretion

Preferred Endodontist

Dr Erika VinczerFirst Available Endodontist

Referral by

Title

Contact Details

Supporting Files

Click on the folder icon to upload files. To upload more than one file, just click on the icon again until all your files are listed before submitting.