Follow Us:
Location
18 - 3919 Richmond Road SW
Calgary, AB T3E 4P2
Call Us
403-242-9952
Email Us
info@tsoralhealth.com
Home
About Us
Meet Dr Shackleton
Meet Our Team
Our Office
Services
Root Canal
Tooth Extractions
Bone Grafting
Non-Surgical Endo Treatment
Apicoectomy
Non-Surgical Perforation Repair
Treatment of Root Resorption
TMJ
TMJ / Orofacial Pain
Oral Appliances
Motor Vehicle Accidents
Independent Dental Evaluations (IDE)
Dental Status Examinations (DSE)
Oral Medicine
Biopsy Service
Oral Lesions
Oral Thrush
Burning Mouth Syndrome
Mucocele Treatment
Trigeminal Nerve Pain
Aftercare
Referring Doctors
Patient Form
Patient Registration
Blog
Contact Us
forms
Dr. Tom Shackleton DDS – Referral Form
Referring Doctor
Referring Doctor Phone
This is to introduce
to your office for endodontic examination of tooth/teeth numbers:
Patient Phone:
Please evaluate for the following conditions/treatment:
Periapical Radioluscency
Yes
No
Elective Endodontics
Yes
No
Post/File Removal
Yes
No
Pulp Exposure - Please Treat
Yes
No
Extraction with socket preservation
Yes
No
Retreat Existing RCT
Yes
No
Place Core Upon Completion of RCT
Yes
No
Tooth Accessed - Please Treat
Yes
No
Others
Yes
No
Notes:
Top
Call Us 403-242-9952
Email Us info@tsoralhealth.com