Endodontic Referral Form
Provided by Endo Mastery
What is your practice name?
What are the names of the doctors in your practice?
What is the name of your office manager?
Best email address for admin to admin correspondence?
Best email address for doctor to doctor correspondence?
Best email address in which to send the encrypted treatment reports?
Would you like the final report sent by mail or email to your office?
Mail
Email
Please provide the mailing address or email address to which you'd like the report mailed.
Would your office like us to place a final filling on an anterior tooth?
Yes
No
See Referral Slip
Would your office like us to place a final filling on posterior teeth?
Yes
No
See Referral Slip
If the tooth is crowned, would you like us to place a temporary filling or a final filling?
Temp
Final
See Referral Slip
If the tooth requires a crown, would you like us to complete the build-up?
Yes
No
See Referral Slip
If the tooth needs to be retreated, would you like us to place a final or temp filling?
Temp
Final
See Referral Slip
If the patient's symptoms stem from periodontal involvement, do you want the patient referred back to you?
Yes
No
If you answered "No" to the above question, what periodontist do you prefer?
If the patient requires an extraction, do you want the patient referred back to you for the extraction?
Yes
No
If you answered "No" to the above question, what oral surgeon do you prefer?
Do you routinely use Nitrous Oxide in your office?
Yes
No
With which dental insurances are you contracted?
Do you have any upcoming vacations scheduled? Would you like us to be “on call” for you?
Would you like us to call and schedule crown appointments prior to the patients leaving our office?
Yes
No
What days are you open? What are your hours?
Do you enjoy the complimentary lunches?
Yes
No
What is the most important thing you would like from us?
What can we as an office improve to better serve you?
Submit
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