Referring Doctors Please fill out form to refer your patients. Introducing(required) Referred by Dr.(required) Referred for Evaluation None Selected Suspicious Radiolucency Traumatic Injury Retreatment Apical Surgery Vague Toothache Referred for Root Canal Therapy None Selected Radiograph Reveals Need Carious Pulp Exposure Needed for Restoration Symptoms Indicate Need Right Top (choose teeth to be examined) 1 2 3 4 5 6 7 8 Right Bottom 32 31 30 29 28 27 26 25 Left Top 9 10 11 12 13 14 15 16 Left Bottom 24 23 22 21 20 19 18 17 Comments(required)