JL Endodontics Referral Form

JJLL ENDODONTICS
*Certified Specialist in Endodontics
Jeffrey Lo
B.Sc, DDS, GPR.,MS., Cert.(Endodontics), FRCD(C)
www.JLendodontics.com/ email: JLendodontics@gmail.com
South office:
University Professional Centre
7603 109 Street Edmonton-#206
DATE:Opening
_________________
Under Construction:
February/March 2015
North Office:
10038-164 Street, Edmonton, AB, T5P 4Y3
T: 780- 487-1010/ F: 780-487-8854
Appointment also available for selected evenings and weekends
INTRODUCING: _________________________________________________DOB: _________________________
Address: _______________________________________________Telephone: ___________________________
Tooth/Teeth: ________________________________________________________________________________
Referral requests:
Remarks
o
Consult only
o
Consult and treatment
o
Pre-prosthodontic treatment
o
Trauma/ Emergency treatment
o
Please call to discuss.
Tooth Status:
o
Recent restoration?
o
Endodontic treatment is initiated.
o
Crown/ bridge is cemented temporarily.
Yes
No
Restoration Requests:
o
Leave post space.
o
Restore access permanently.
Signed:
DR.
South Office
North Office
For specific
please visit
directions,
www.JLendodontics.com.