Referring Doctors Form

Date:

Patient's Name:

Tooth#:

Referring Doctor:

Please indicate reason for referral: Evaluation
Consult for Sedation
Conebeam CT scan
Root Canal Treatment
Retreatment
Microsurgery

Please indicate restorative preference: RCT Only
Leave Post Space
Crown Build-Up

*Please e-mail (info@baysideendo.com) or mail the patient's x-rays to our office.

Comments:

Do you prefer E-Referrals, or printed referral slips? We have three ways you may refer patients to our office. Please choose your preferred option below.

We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form below.