Printable Referral Form
Print this form and include it with any X-rays or clinical photos.
Patient Referral Form
Premier Endodontics Dental Group
Dr. Preeti Sandhu | Dr. Sean Noorvash
1820 Fullerton Ave, #220
Corona, CA 92881
Phone: (951) 279-2251 | Fax: (951) 279-5607
Referring Doctor Information
Patient Information
Reason for Referral
Consultation Only
Root Canal Treatment
Root Canal Retreatment
Apicoectomy / Endodontic Surgery
Trauma
Post Removal
CBCT Scan
Other: _______________
Clinical Information
Pain
Swelling
Sensitivity to Hot/Cold
Biting/Chewing Pain
Sinus Tract / Drainage
Fracture
History of Trauma
Pulp Exposure
Tooth / Teeth Needing Treatment
Upper Right
1
2
3
4
5
6
7
8
Upper Left
9
10
11
12
13
14
15
16
Lower Left
17
18
19
20
21
22
23
24
Lower Right
25
26
27
28
29
30
31
32
Restorative Request
Leave Post Space
Place Core Build-Up
Place Post and Core
Place Temporary Restoration
Place Final Restoration
Please Call Me
Attachments
Current Radiographs Attached
Clinical Photos Attached
Medical History Form Attached
X-rays Will Be Sent Separately
Additional Notes / Special Instructions
Section