PLEASE MARK THE TOOTH TO BE EXAMINED / TREATED
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9101112131415162423222120191817
Reason for Referral: Consultation and TreatmentPulp exposureIntentional RCT for restorative reasonsInternal bleaching
Restorative Instructions: Buildup as neededLeave post spaceTemporary filling
Miscellaneous: Call me about this caseCrown/BridgePermanently cementedTemporarily cemented
Radiographs: Given to patientHave been mailed or e-mailed
Previous Dental History: Most recent restoration and date: Pulpotomy/Pulpectomy performed on: Previous RCT performed on:
PLEASE MARK THE TOOTH TO BE EXAMINED / TREATED 123456783231302928272625
Treatment To Be Performed Consultation OnlyPeriapical radiolucency presentPulp exposureRCT required for proper restorationEvaluation for endodontic surgeryRoot canal therapy
Restorative Instructions Place post and build-upLeave post spacePlace temp in access cavityPlace final restoration in access cavity
Tooth Numbers 12345678910111213141516171819202122232425262728293231303132
