2556 Apple Valley Rd. Suite 150, Atlanta, GA 30319 (404)-264-1944

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Doctor Referral

Refer a patient to Endodontics of Buckhead

Referral Form

Submit a Patient Referral

Welcome to our Endodontic practice. We specialize in root canal therapy and have many years of experience. Fill out the form below and our team will follow up promptly.

Patient Name *

Patient Phone *

Referring Doctor *

Office Phone *

Office Email

Date

Tooth Number(s)

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 32

Areas of Interest

Endo Consult & Treat as necessary Apicoectomy & Retrofill

Post?

Metal Fiber None

Post Space Only?

Yes No

Permanent Repair of Access?

Yes No

Patient Signs and Symptoms in Your Office

Pain Level

1 2 3 4 5 6 7 8 9 10

Cold

+ ++ +++

Heat

+ ++ +++

Percussion

+ ++ +++

Bite Pressure

+ ++ +++

Fistula

Yes No

Crown Cement

Temporary Permanent

Swelling

Additional Notes

X-Rays / Photos

Drag & drop files here or click to browse

JPG, PNG, PDF, DICOM accepted

2556 Apple Valley Rd. Suite 150
Atlanta, GA 30319

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Office Hours

Mon: 9:00am - 5:00pm

Tue: 9:00am - 5:00pm

Wed: 9:00am - 5:00pm

Thu: 9:00am - 5:00pm

Fri: 9:00am - 1:00pm

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