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| Patient: | Tooth# | Date |
| "endo.fr" . |
| endodontic practices: | Jean-Jacques DUPUIS, DDS, MS, FICD |
| . Referral Pro Forma | |
| Referring doctor: | dr_Last
Name: |
dr_First Name: |
City: |
| dr_Telephone: |
dr_Mobile: |
Fax: | |
| Specialty: | e-mail: | ||
| Patient details: | patient_Last Name: |
patient_First Name: |
DoB: |
| patient_Telephone: |
patient_Contact
address: | ||
| Mobile: |
City: |
ZIP code: | |
| Reason for referral: (pain &
infection) click on most relevant symptom |
Reason for
referral:(mechanical) click on most relevant description |
| Main patient's
complaint & demand |
| Investigate & treat | Opinion only | Anxious | Apicectomy |
| Clinical details (optional) | Tick if your answer is "Yes" | ||||||
| Pain? | Swelling? | Tooth vital? | PA lesion? | ||||
| Recent restoration? | Previous RCT? | Self? | Other? | ||||
| Ag? | GP? | Paste? | Instrument separated? | ||||
| X-rays to be sent by e-mail? Yes or No | |||
| ask for help to digitize x-rays |
| Observations | |
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| Jean-Jacques DUPUIS, DDS, MS, FICD - Endodontics, Implantology - Tel. 079 3323 8649 - E-mail:paris@odonto.fr - Website: www.endo.fr | |||
| . | |||
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