Refer A Patient - Teeth. Q Dental Surgeons

REFERRAL FOR
ROOT CANAL TREATMENT

*All patients will be referred back to the referring dentist
for other treatment needs

REFERRAL FOR ROOT CANAL TREATMENT

"*" indicates required fields

Referring Dentist

Dentist’s name

Contact

Clinic name

Patient Particulars

Patient's name*

Mobile*

Tooth Concerned

Treatment Required (tick those that apply)

Crack or Pain assessment and management

Root canal treatment or Retreatment

Elective root canal treatment

Others

Post Obturation

Require placement of core

Core to be placed by the referring dentist

Referral notes

You can choose to either upload relevant radiographs or documents
through the link below or send them to us via email (enquiry@teethq.com)
or Whatsapp (8522 5374 – teethq.com/wa). Thank you!

Upload of Relevant Radiographs and Documents

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB, Max. files: 5.

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