Referral Form Please email the form below to info@heritageendooc.com or submit the online referral form. Thank you! Online Referral Form Referring Doctor * Patient Name * First Name Last Name Patient Email * Patient Phone * (###) ### #### Tooth # * Service Requested * Consult only Evaluate and treated as needed Root canal treatment Root canal retreatment Apical surgery Internal bleaching Endo tx for restorative reasons Please call prior to tx History * Check all that apply Pain to Cold or Hot Pain to Biting Swelling/Sinus Tract PA Radiolucency Resorption Trauma Pulp Exposure RCT initiated Cracked tooth Access Filling * Sponge/Cavit Post Space Core Build-up Post/Core Additional Comments Anything else we should know? HIPAA Privacy Notice * Please do not submit personal health information through this form unless you are comfortable with electronic transmission of your data. While we take precautions to protect your information, our online forms may not be fully HIPAA-compliant. For your privacy, you may call our office directly at 714-995-5168 to share sensitive details. I have read and understand the HIPAA Privacy Notice. I consent to the electronic transmission of my information for the purpose of scheduling my appointment. Thank you! Our office will contact you shortly. You may also give us a call to schedule your appt.
