Referral

You can refer your patient by filling out the form below or by printing out our referral form and faxing it to:
(603) 424-3066 Referral Form

Office Email * *

Patient First Name * *

Patient Last Name * *

Home Phone

Work Phone

Cell Phone

Referred by Dr.

Receptionist

Appointment Date & Time

For consideration of the following

Endodontics

Consultation

Please provide Quadrant (R-L) and Tooth number

Type

Trauma

Previous endodontic treatment

Pulp exposed

Tooth open for drainage

Patient has discomfort, please evaluate

Radiographic findings present

Bridge /crown cemented - Temporarily

Bridge /crown cemented - Permanently

Pretreatment

Post removal

Finishing

No post space

Post space only

Core composite buildup

Upload Radiograph

Comment

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