Referring Professionals

Please fill in the referral form below.

Dear colleagues,

Optimal quality of dental care is the goal of every clinician. Achieving this goal requires a successful, honest and constructive collaboration between the referral dentist and the endodontist.

In our practice we undertake exclusively endodontic cases - microsurgical and non-surgical - always in direct contact with the referral dentist.

After the root canal treatment, the patient returns back to the referral dentist for the completion of the treatment plan. Also, a follow-up examination is performed in order to evaluate the therapeutic result.

Below you can see and fill in the patient's referral form. In case you wish to receive a hard copy booklet of referral forms, you can contact us at


Fields with an * are mandatory.
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Upper Right Quadrant

Upper Left Quadrant

Lower Right Quadrant

Lower Left Quadrant

This tooth/teeth require(s) root canal therapy:
This Tooth/Teeth Require(s) Retreatment:

Existing Crown/Bridge
Crown will be Replaced

Please fill in all fields with an asterisk.
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