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Endodontic Referral Form

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Patient Details

Patient's Name*

Patient's Email Address*

Patient's Address*

Street Address Address Line 2 City Post Code

Patient's Phone Number*

Patient's Date of Birth*

DD slash MM slash YYYY

Referring Dentist's Details

Dentist's Name*

Practice Name*

Practice Address*

Street Address Address Line 2 City Post Code

Dentist's Phone Number*

Dentist's Email*

Dentist's GDC Number*

Referral Details

Type of Referral*

Please tick as required

Consultation and Report Only

Primary Root Canal Treatment

Root Canal Re-Treatment

Other Factors*

Please tick as required

Canal blockage

Difficult access

Post removal

Unable to locate all canals

Instrument removal

Trauma

Perforation or root resorption

Post and core build-up required

None

Tooth/Teeth to be Treated*

Details

Restoration and Aftercare Preferences

After completion of endodontic treatment:*

Return the patient with a permanent seal in the access cavity for their own GDP to provide the definitive coronal restoration

Provide the definitive coronal restoration at Crescendo

If we are unable to provide endodontic treatment:*

Advise the patient to return to their GDP for next steps

I give permission for implant options at Crescendo to be discussed with the patient

Attachments

Please provide us with an up-to-date periapical radiograph of the tooth/teeth to be treated.

Do you have files to upload in support of this referral?

Yes

File Uploads*

Please Include Any Relevant File Attachment such as Radiographs, Clinical Notes Or Photographs

Drop files here or

Accepted file types: jpg, pdf, doc, docx, png, Max. file size: 512 MB.

Be assured that we advise patients to continue seeing their own dental practitioner for their regular routine examinations and treatment.

We will only definitively restore the tooth/teeth being endodontically treated if you specifically request us to do so.

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