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.