Referring Doctors:

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Patient Name

First Name

Last Name

Patient Date of Birth

MM

DD

YYYY

Patient Phone Number:

Referring Doctor:

Description

Diagnosis and Tooth Number

Treatment Request:

Referred For:

Evaluation/ CBCT

Initial Root Canal Treatment

Retreatment

Endodontic Microsurgery/ Apicoectomy

Restore

When treatment is complete:

Restore with Build Up

Temporize

Prepare Post Space

Comments:

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https://referrals.dentalemr.com/~/84/login

Don't have an account? Contact the practice to obtain your credentials to refer cases and receive reports.

Our member portal allows you to track your patients treatment and receive referral reports online!

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