5025 Parkwood Rd Unit 4, Blackfalds, AB T0M 0J0
Please complete all applicable fields and submit securely to our office.
1 Referring Dentist
Referring Dentist *
Practice Name *
Phone *
Fax
Email *
Date *
2 Patient Information
Patient Name *
Date of Birth *
Email
Tooth/Teeth Referred *
3 Reason for Referral
ImplantsIV SedationHot Tooth/Hard to freezeHopeless tooth extraction and bone graftingEndodontic EvaluationRoot Canal Therapy (RCT)Retreatment (Anterior Only)Endodontic Surgery (Apicoectomy) (Anterior Only)Trauma EvaluationCracked Tooth AssessmentInternal ResorptionExternal ResorptionCalcified Canal(s)Persistent SymptomsDiagnosis OnlyOther
If Other, Please Specify
4 Clinical Findings
Chief Complaint
Clinical Findings
Pulp Testing Results
Percussion PositiveNegative
Palpation PositiveNegative
Mobility
Periodontal Findings
5 Radiographic Findings
Periapical Radiograph AttachedBitewing AttachedCBCT AvailableDigital Images Emailed
Findings
6 Requested Treatment
Please evaluate and treat as indicated.Complete root canal therapy and return patient for final restoration.Evaluate only; no treatment without consultation.Emergency treatment/pain relief.
Other Instructions
7 Medical Considerations
8 Additional Comments
Referring Dentist Signature *
Thank you for your referral. We appreciate the opportunity to care for your patient and will return them to your practice upon completion of treatment.
