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Governors Endodontics Online Referral
If you are a doctor who is referring a patient to us, please fill out and submit the following form.
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* Indicates required question
Referring Doctor's Name
*
Your answer
Referring Doctor's Email
*
Your answer
Referring Doctor's Phone
*
Your answer
Patient Name
*
Your answer
Patient Email
*
Your answer
Patient Phone
*
Your answer
Tooth Number
*
Your answer
Referral For
*
Evaluation
Root Canal Treatment
Retreatment
Apical Microsurgery (Apicoectomy)
Other
Other:
Required
Please Restore With
Temporary Restoration
Leave Post Space
Permanent Composite
Permanent Amalgam
Other:
If the tooth is non-restorable or fractured
Return patient to my office
Extract During Endo Visit
Refer to Perio/OS
Radiograph(s) to be sent to Hello@GovernorsEndo.com
Yes
No
Clear selection
Additional Information
Your answer
Submit
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