REFER A PATIENT BELOW L. Björn Jönsson, DDS, MS Charles Tatosian, DDS, MS Wayland Chu, DDS, MSD www.sbvendo.com : 949-581-8890 : 949-581-3902 : office@sbvendo.com Date: Introducing: Referring Doctor: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 REMARKS Asymptomatic Symptomatic Periapical radiolucency Exposure / deep decay Prior RCT Coronal crack Root fracture? Resorption? RESTORATIVE HISTORY / PLANS Recent restoration Adequate restoration Questionable restoration New restoration planned APPOINTMENT INFORMATION Scheduled on Patient will call to schedule Contact patient at to schedule an appointment TREATMENT REQUESTS: Consult and treat if indicated Intentional RCT RESTORATIVE REQUESTS: Temporize and refer back to office Leave post space If you feel indicated Permanently restore access Build-up and refer back for new crown / bridge Place post If you feel indicated IF EXTRACTION IS NEEDED, REFER PATIENT: Back to office To Print completed referral Submit completed referral online After clicking submit you will have the option to: Attach and share patient images Add additional private information or comments Print a paper copy of the completed referral with map to give to the patient Print a digital copy for your records Need more paper referral slips? Want to print some extras? Print blank referral slip now
