Referring doctors - Centre Endodontique Saint Laurent

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Referring doctors

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Referring doctors

Referring doctors

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Date *

Referring dentist

Dr. *

First

Last

Phone 1 *

Phone 2

Email *

Patient

Multiple Choice

Mr.
Ms.

Name *

First

Last

Phone 1 *

Phone 2

Email

Date of birth *

Canadian Dental Care Plan *

Yes
No

Tooth (Teeth)

Teeth Top

18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28

Teeth Bottom

48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38

Treatment

Emengency treatment
3D Scan
Diagnosis
Root canal treatment
Retreatment
Apical surgery
Apexification or regeneration
Intentional replantation
Internal bleaching
Trauma management
Internal or External Resorption

Restore with

Cotton pellet & temporary restoration
Final composite

Post Space

Yes
No

Files

Attach your Xrays (.pdf .jpg)

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No special characters in file name please.

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