Referral Form

For dentists only

You can fill out the form below and submit it to Bay Bloor Endodontics electronically, or you can download it as a PDF, fill it out, and send it with the patient.

Referral Form (pdf)

Patient Referral
  1. (required)
  2. (valid email required)
  3. (required)
  4. (valid email required)
  5. Please Evaluate

Patient has been informed that:
  1. non-surgical root canal therapy required

  2. surgical root canal therapy required

  3. re-treatment of previous root canal therapy required

  4. emergency treatment will be rendered

I have prescribed the following medications:
Patient would be interested in:
  1. nitrous oxide

  2. oral sedation

  3. IV sedation

  4. general anaesthesia

  1. Crown or Bridge is cemented:
  2. Need for full coverage discussed:
  3. Post space required:
  4. Please contact me personally