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Our Locations
Austin
Round Rock
San Marcos
Meet Our Team
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Date:
Patient Name:
Referring Doctor:
TREATEMENT TO BE PERFORMED:
Consultation Only
Periapical radiolucency present
Pulp exposure
RCT required for proper restoration
Evaluation for endodontic surgery
Root canal therapy
RESTORATIVE INSTRUCTIONS:
Place post and build-up
Leave post space
Place temp in access cavity
Place final restoration in access cavity
TOOTH TO BE EVALUATED:
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
MISCELLANEOUS:
Call me about this case
Crown and bridge is cemented
Temporarily
Permanently
SPECIAL INSTRUCTIONS:
