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Referring Dentist

Radiographs

*CBCT is not necessary, and will be repeated at our office if required.

Tooth/Teeth to be evaluated
Tooth/Teeth to be evaluated
Tooth/Teeth to be evaluated
Tooth/Teeth to be evaluated
Reason for Referral
Restorative Instructions
In the event that the tooth cannot be saved, please indicate if you wish to have the tooth extracted at our office: