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Location
18 - 3919 Richmond Road SW
Calgary, AB T3E 4P2
Call Us
403-242-9952
Email Us
info@tsoralhealth.com
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Root Canal
Tooth Extractions
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Non-Surgical Endo Treatment
Apicoectomy
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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:
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Call Us 403-242-9952
Email Us info@tsoralhealth.com