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Endodontic Referral

Lets dental practices register how they prefer to work with an endodontic specialist. It collects contact emails, clinical preferences for fillings and follow-up referrals, plus practical details such as hours and insurance networks.

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What is your practice name?

What are the names of the doctors in your practice?

What is the name of your office manager?

Best email for admin-to-admin correspondence

Best email for doctor-to-doctor correspondence

Best email to receive the encrypted treatment reports

Would you like the final report sent by mail or email to your office?

Postal mail Email Both

Provide the mailing or email address where we should send the report

Would your office like us to place a final filling on an anterior tooth?

Yes No Case by case

Would your office like us to place a final filling on posterior teeth?

Yes No Case by case

If the tooth is crowned, would you like a temporary or a final filling?

Temporary filling Final filling Case by case

If the tooth requires a crown, would you like us to complete the build-up?

Yes No Case by case

If the tooth needs to be retreated, would you like a final or a temporary filling?

Final filling Temporary filling Case by case

If the patient's symptoms stem from periodontal involvement, do you want the patient referred back to you?

Yes No Case by case

If you answered "No" above, which periodontist do you prefer?

If the patient requires an extraction, do you want the patient referred back to you for it?

Yes No Case by case

If you answered "No" above, which oral surgeon do you prefer?

Do you routinely use nitrous oxide in your office?

Yes No Occasionally

With which dental insurances are you contracted?

Do you have upcoming vacations scheduled? Would you like us to be on call for you?

Would you like us to schedule crown appointments before patients leave our office?

Yes No Sometimes

What days are you open and what are your hours?

Do you enjoy the complimentary lunches?

Yes No Sometimes

What is the most important thing you would like from us?

What can we improve to serve you better?

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