Dentist Referral Links | Pheiffer Endodontics

top of page

Home
About
FAQ
Fee Structure
Referrals & Forms
- Dentist Referral Links
- Patient Information Forms

Dentist Referral.png

Download the dentist referral form, or fill in the details below.

Referring Dentist

Date Of Birth

Tooth # or Affected Area

Recent Treatment

Restoration/Temporary

Crown/Temporary

Pulp Cap

Pulpotomy

Periodontal Treatment

Endodontic Procedures Requested

Evaluate and treat as necessary

Evaluate only/consult Doctor before proceeding

Non-surgical Retreatment

Surgical Evaluation and Treatment

Patient Name

Phone Number

Email Address

Status of the Tooth

Symptomatic

Asymptomatic

Emergency Treatment has been performed

Previous Endodontic Treatment is failing

Fractured Tooth/Restoration

Radiography

Please email radiographs to: info@drstefan.co.za or send with patient.

PAN

PA

MANAGEMENT, MEDICAL OR TREATMENT CONCERNS:

CBCT

RESTORATIVE TREATMENT PLANNED

Full Coronal coverage

Other:

Thanks for submitting!

Designed and Maintained by BUILD.AI

© Copyright 2024 Pheiffer Endodontics | All Rights Reserved

bottom of page