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Referrals
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Referral Form
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Referral Form
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I would like to refer my patient to one or any of these endodontists :
Marina Braniste, DMD, MS
Pierre-Olivier Miron, DMD, MS
Gilbert Thellend-Gauthier, DMD, MS
Cathy Vu, DDS, MS
Referral to the following location(s):
Ville Mont-Royal
Rosemère
Doctor’s Information
Name
*
First
Last
Phone Number
*
E-mail
*
Clinic’s Name
*
Clinic’s Address
*
Patient Information
Miss
Mrs
Mr
Date of birth
*
DD slash MM slash YYYY
Full name
*
Phone number
*
E-mail
*
The patient must communicate with us at the following phone number - 514-344-3636 - to book an appointment. All the pertinent information regarding the booking of his/her appointment will be sent to him/her by email upon completion of this form.
Complimentary information:
Tooth / Teeth to be examined
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
Please specify
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Treatment(s) needed
*
Consult
CBCT
Root canal treatment
Root canal retreatment
Apical surgery
Trauma follow-up
Autre Other
Please specify
Reasons for consult:
*
Symptoms
Trauma
Lesion/Fistula
Resorption
Pre-prothetic treatment
Previous root canal treatment
Treatment started but couldn’t finish
Notes
What restauration would you like the endodontist to place?
*
Temporary
Composite
Amalgame
Post / Core Build-up.
What restauration are you planning to place following the endodontie treatment?
*
Composite
Amalgame
Crown
Onlay/Inlay/ CEREC
Would you like a post-space?
*
Yes
No
According to your opinion
Comments
Please attach the necessary radiographs regarding your referral.
Accepted file types: jpg, pdf, png, Max. file size: 15 MB.
I don’t have radiograph for this particular referral / I will send the non-digital radiographs by mail.
Name
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