London endodontist

ANTHONY C S DRUTTMAN M.Sc. B.Sc. B.Ch.D.

SPECIALIST IN ENDODONTICS

Endo specialist London Root canal expert London
 020-7935-9943
Endodontics Referral Form
Refer your endodontics case by completing the online form. Alternatively you can refer by telephone or post.
Note: * = required field

Patient: *
First Name
Surname

Date: *

Phone: *
(please enter
at least one)
Home
Work
Mobile

e-mail: 

Address: *
DENTAL PLAN *
RIGHT | LEFT

18

17

16

15

14

13

12

11
   
21

22

23

24

25

26

27

28

   

48

47

46

45

44

43

42

41
 
31

32

33

34

35

36

37

38

STATUS: *


TREATMENT REQUESTED: *

Acute symptoms, pain and or swelling Diagnosis/ consultation only
Pulp exposed and bleeding - dressing and temporary filling inserted Examination and treatment as required
Pulp exposed and necrotic material present Prepare post space if deemed necessary
Tooth is open for drainage Do you have images / photos
to send us?


Comments:
Endodontic treatment started and difficulties experienced if so, what?
Radiograph included - Dated:
Radiograph to be sent either by e-mail or by regular post (in other cases, we will require a consultation appointment first)
Patient has vague discomfort - please evaluate
Bridge/crown is cemented.
Temporary Permanent
Elective Endodontic Treatment
Does your patient require Nitrous Oxide Sedation?

Referring Dentist: * Endodontics London


To Tony Druttman,
Specialist in Endodontics
Work Phone: *
E-mail: *
Enter the code: *
Change Code
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