Referring Doctors:

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Patient Name

First Name

Last Name

Patient DOB:

Referring Doctor:

Description

Diagnosis and Tooth Number

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Referred For:

Evaluation/ CBCT

Initial Root Canal Treatment

Retreatment

Endodontic Microsurgery

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When treatment is complete:

Restore with Build Up

Restore with Post and Core

Temporize

Prepare Post Space

Effingham Endodontist