Endodontic Referral

Please use the form below to refer a patient for endodontic assessment only or click here to download a printable version. For all other cases use the Prosthodontic referral page. Alternatively, please contact us to discuss your case.

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Referring Dentist Name*

Referring Dentist Email*

Referring Practice*

Patient Name*

Patient Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Patient Contact Number*

Patient Email*

Patient Date Of Birth*

Relevant Clinical Information

Relevant Medical History*

Current Medication*

Teeth referred for treatment

Teeth referred for treatment Box 1

Teeth referred for treatment Box 2

Teeth referred for treatment Box 3

Teeth referred for treatment Box 4

Reason for referral

Diagnosis

Referral Specifically for Specialist Treatment

Root canal treatment

Apical surgery

Additional information

Is the patient in pain?

Has the tooth already been accessed or treatment attempted?

Previous root canal treatment?

Radiographs

Drop files here or

Accepted file types: jpeg, jpg, gif, giff, png, Max. file size: 15 MB, Max. files: 5.

Upload radiographs and images of the case in the following formats jpeg, jpg, gif, giff, png Up to 5 images allowed, max size 3MB per image

No requirement for post or core?

(Composite core placed as standard)¹

Tooth requires post-space preparation<sup>2</sup>

Tooth requires post-space preparation

Further relevant information

Explanatory Notes:

It may be necessary to remove the core to allow direct assessment of the underlying tooth structure. Please indicate if you would NOT like the coronal structure to be stabilized as part of treatment.
A composite resin core will be used as standard. Please select if you would like the tooth to be prepared with a post space on completion of treatment. Parapost system used unless otherwise specified.

Prosthodontic Referral

Refer Now

Refer a patient

Relevant Clinical Information

Explanatory Notes:

Prosthodontic Referral

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