Referral Form - La Jolla Micro Endodontics

Introducing
Patient Phone
Referring Doctor
Please select all that apply:
- Consultation only
- Patient in pain, treat as needed
- Root Canal necessary for restoration
- Vital pulp exposure, treat as needed
- Tooth has been opened
- Prior RCT tx: evaluate for retx or sx
- Place Post Space
- Place final buildup
Tooth Number(s)
Please upload any necessary files:
Max. file size: 100 MB.
*Please do not take pain medication 6 hours prior to consultation appointment.

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