Reference form

In order to accommodate you, the medical form that we ask you to complete when you arrive at the clinic is also available online. Please make sure that the required fields are completed correctly.

1 - Please identify who you would like to refer to :

2 - Patient information








Do you have a preference for an Endodontist ?

3 - Required care

Right Left
 
 
 

4 - Performed tests and additional information

Required pivot space *

Type of shutter materials present

Performed tests (must include adjacent teeth)
Teeth #
Cold
Palpation
Percussion
Mobility
Probing
Tooth slooth

5 - Radiography sent ...

Radiography : (maximum 2 mo by file)