Call for an appointment: Langley, British Columbia (604) 532-4090

REFERRAL INFORMATION

REFERRING DOCTOR

Name:

Phone:

Date:

 

 

WE ARE REFERRING

Patient:

Home Ph:

Work Ph:

Cell Ph:

Insurance Information

Policy Holder's Name: Birth Date:
Employer:
Insurance Co:
Group Plan #:   Certificate #:   Dep. #:
Relationship To
Policy Holder:

Secondary Insurance Plan

Policy Holder's Name: Birth Date:
Employer:
Insurance Co:
Group Plan #:   Certificate #:   Dep. #:
Relationship To
Policy Holder:

 

REASON FOR REFERRAL

Tooth Status

R


8


7


6


5


4


3


2


1


1


2


3


4


5


6


7


8

8

7

6

5

4

3

2

1

1

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8
L

 Patient Has Pain/Swelling/Discomfort

 Endo Has Been Initiated
 X-ray Reveal Apical Radiolucency  Crown Cemented
 Previous RCT is Failing  Temp        Permanent

 

Treatment Request

Close Access With
 Non-Surgical Endodontics  Temp Restoration
 Surgical Endodontics  Composite
 Evaluation Only  Amalgam
 Leave Post Space

Comments

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Langley Endodontics

 Dr. Howard Bittner - Root Canal Specialist
#303-6351 197th Street
Langley, B.C.   V2Y 1X8
Phone: (604) 532-4090 / Fax: (604) 532-4084