Dentist Referral Form
We have prepared a
Specialist Referral Guide
, available in PDF format. Please help us get started on your patient referral: (The following confidential information is for our records only)
“Please fill out required fields as denoted by *”
Specialist To Whom You Are Referring:*
Phil Shedletsky, DDS, MS
Gary Glassman, DDS, FRCD(C)
Glen Partnoy, DDS, MS, FRCD(C)
Simone Seltzer, DDS, FRCD(C)
Adam Grossman, DDS, FRCD(C)
Gevik Malkhassian, DDS, MSC, FRCD(C)
Jose A. DaCosta, DDS, MSC, FRCD(C)
No preference, first available Endodontist
To which office are you referring this patient?*
1235 Bay St.
145 King St. W.
Patient's Name:*
Date of Birth:*
Telephone Number
Email Address
Endodontic Consideration of the Following Teeth: (1) (maxillary right quadrant)
8
7
6
5
4
3
2
1
Endodontic Consideration of the Following Teeth: (2) (maxillary left quadrant)
1
2
3
4
5
6
7
8
Endodontic Consideration of the Following Teeth: (3) (mandibular left quadrant)
1
2
3
4
5
6
7
8
Endodontic Consideration of the Following Teeth: (4) (mandibular right quadrant)
8
7
6
5
4
3
2
1
Tentative Diagnosis:
Reason for referral
Please call
Pulp Exposed
Patient has discomfort
Bridge Cemented
Post space required
Parallel
Taper
in which canal(s):
Temporary or Permanent?*
N/A
temporarily
permanently
Comments:
Upload X-ray (optional):
Select a file
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Signed, Dr.
Office Address
Your contact Phone number to here
Your E-mail Address to here