Specialist To Whom You Are Referring:

Phil Shedletsky, D.D.S., M.S.
Gary D. Glassman, D.D.S., F.R.C.D.(C)
Glen Partnoy, D.D.S, M.S, F.R.C.D.(C)
Rita Kilislian, D.M.D., Cert. Endo.
Simone Seltzer, D.D.S, F.R.C.D.(C)

To which office are you referring this patient?

Patient name:

Endodontic Consideration of the Following Teeth:

1	8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8	2
4	8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8	3

Tentative Diagnosis:

	Please call
	Pulp Exposed
	Patient has discomfort
	Bridge Cemented
	Post space required
	Parallel
	Taper
in which canal(s):
temporarily permanently

Your contact phone number:

Comments:

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Signed, Dr.