Referral Location
Mankato Office - 1570 Adams Street
Albert Lea Office - 1206 W. Front Street
Patient Information
DOB:
Referring Doctor Information
Tooth Number
1
1
2
2
1
3
1
4
1
5
1
6
1
7
1
8
1
9
1
10
1
11
1
12
1
13
1
14
1
15
1
16

32
32
31
31
30
30
29
29
28
28
27
27
26
26
25
25
24
24
23
23
22
22
21
21
20
20
19
19
18
18
17
17

Appointment Type
Evaluate Only
Evaluate for non-surgical retreatment and/or surgery
Tooth is ready for treatment - please treat
Root canal started on:
Treatment Instructions
Patient requires a premedication and has a prescription
Create post space
Place permanent restoration:
  • Amalgam
  • Composite
Refer patient back to our office for permanent restoration
Radiographs or Clinical Photos
TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE CLICK SUBMIT BELOW.
Case Notes
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