Endodontic Referral

Referrer Details

Patient Details

Tooth / teeth to be evaluated / treated

(select all teeth to be assessed)

You will receive an email of acknowledgement within 7 working days to confirm receipt of this referral.

Please note that if you refer your patient with a CBCT scan there will be an additional reporting charge for the patient. This is due to the additional time necessary to report on these complex scans.

Referring dentist's signature