A
NTHONY
C S D
RUTTMAN
M.Sc. B.Sc. B.Ch.D.
S
PECIALIST IN
E
NDODONTICS
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Endodontics Referral Form
Refer your endodontics case by completing the online form. Alternatively you can refer by telephone or post.
Note:
*
= required field
Patient:
*
First Name
Surname
Date:
*
DD
1
2
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5
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8
9
10
11
12
13
14
15
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17
18
19
20
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30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2010
2011
2012
2013
2014
2015
Phone:
*
(please enter
at least one)
Home
Work
Mobile
e-mail:
Address:
*
DENTAL PLAN
*
RIGHT
|
LEFT
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
STATUS:
*
TREATMENT REQUESTED:
*
Acute symptoms, pain and or swelling
Diagnosis/ consultation only
Pulp exposed and bleeding - dressing and temporary filling inserted
Examination and treatment as required
Pulp exposed and necrotic material present
Prepare post space if deemed necessary
Tooth is open for drainage
Do you have images / photos
to send us?
Comments:
Endodontic treatment started and difficulties experienced if so, what?
Radiograph included - Dated:
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YY
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
12
Radiograph to be sent either by e-mail or by regular post (in other cases, we will require a consultation appointment first)
Patient has vague discomfort - please evaluate
Bridge/crown is cemented.
Temporary
Permanent
Elective Endodontic Treatment
Does your patient have a preference for location?
Devonshire Street
Finsbury Circus
Does your patient require Nitrous Oxide Sedation?
Referring Dentist:
*
To Tony Druttman,
Specialist in Endodontics
Work Phone:
*
E-mail:
*
Enter the code:
*
Change Code
