Doctor Referral V3 Form

Introducing (patient name)

Patient's DOB

Patient's Phone

Patient's Address

City

State

Zip

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

Restorative Purposes - Elective Root Canal

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

Referred By (doctor's name)

Person completing this form

Referring office email address

Our Endodontists (specialists in saving teeth with root canal treatment) have a combined 44+ years of experience.
Meet our Doctors - check out our website; teethworthsaving.com

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

863.382.9947 • teethworthsaving.com

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

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