Doctor Referral Form

Introducing (patient name)

Patient's DOB

Patient's Address

Patient's Phone

Tooth or area

Today's Date

Select at least one option

Consult for Treatment

Consult for Treatment Planning

Consult for Financial / Insurance Concerns

Patient committed to treatment

Select at least one option

Root Canal Treatment

Retreatment / Apico

Vital Pulp Therapy

Traumatic Injury

Internal Bleach

Select at least one option

Permanent restoration of access opening

Temporary restoration of access opening

Return to our office for crown/bridge

Select at least one option

Cement Post

Post & Build Up

Chamber Retained Buildup - No Post

None

Special Needs: Please check all that apply

Patient is a minor (17 or younger)

Challenging patient management

Physical or mental disability

Limited opening

TMJ pain or concerns

Requires oral sedation

Requests Nitrous Oxide

Patient requires extra time

No Special Needs

Additional Notes

Referred By (doctor's name)

Person completing this form

Referring office email address

Confirm email address

Dr. Gayle Obermayr has 25+ years of experience as an endodontist (specializing in saving teeth with root canal treatment).
Dr. Obermayr earned her dental degree from the University of North Carolina and master’s degree in Endodontics from the University of Iowa. She served as the clinical director of the DATS dental school. Dr. Obermayr is a past President of the Florida Association of Endodontists, Southern Endodontic Study Club and the Greater Highlands Dental Society. Dr. Obermayr is also a member of the ADA, AAE, WCDS and the ACD.

"We are commited to serving you with "Comfort and Excellence."

863.382.9947 • heartlandendodontics.com

4660 Lakeview Drive, Suite 101 • Sebring, FL • 33870

Office is located on the west side of Lakeview Drive, north of Heartland National Bank