Patient Information

You will likely be referred to us by your general dentist, a family member, friend or associate. However, you may call us directly. If you are being referred, you will likely be given a referral slip to be filled in by your dentist. Your referral slip will look similar to what you see below.

1. Patient will return to referring dentist for final restoration.
2. If problems should arise prior to your appointment, please call our office.
3. If you are using dental insurance, please bring necessary information with you.
4. If you are unable to keep your appointment, please call our office so the reserved time may be used by another.
5. Evening and Saturday appointments are available.
6. Minors must be accompanied by a parent or legal guardian at the time of consultation unless prior arrangements have been made.

Date: __________________________, 20_________

Introducing: _____________________________________________________________________ for Endodontic consideration.
(Patient will return to referring dentist for final restoration.)

Appointment Date: __________________________________________________________Time: __________________________

Referring Doctor: __________________________ Please phone at #: ______________Convenient Time: ____________

Upper	1 2 3	4 5	6 7 8 9 10 11	12 13	14 15 16	Upper
Right	MOLARS	BICUSPIDS	ANTERIORS	BICUSPIDS	MOLARS	Left
Lower	32 31 30	29 28	27 26 25 24 23 22	21 20	19 18 17	Lower