Bloomington 812-333-6363
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Bloomington 812-333-6363 Jasper 812-482-7668
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Endodontic Center of Southern Indiana

Doctor Referrals – Bloomington

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Patient Name: *

First

Last

Appointment Date:

Please check the following teeth for endodontic consideration:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Right

Left

32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17

Comments

Doctor:

Pertinent Information

Patient has pain, swelling, or sensitivity
Endodontics
Pulpal / carious exposure
Bony change

Requested treatment

Consultation
Endodontic therapy
Retreatment
Apicoectomy
Root resection
Hemisection
Intentional replantation
Post Space

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Endodontic Center of Southern Indiana

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3901 Hagan Street, Suite B
Bloomington, IN 47401

Phone: 812-333-6363

Hours:
Mondays - Thursdays:
7:30 AM - 4:30 PM

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