Introducing:

Appointment Date: Time:

Referring Doctor:

Comments/Special Instructions:

UPPER

LOWER

R L1 2 3 4 5 6 7 8 9

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

10 11 12 13 14 15 16

molars biscuspids anteriors anteriors biscuspids molars

Patient is having pain and/or swelling

Trauma

Pulp was exposed

Root canal treatment has been started

Prepare post space

3D CBCT radiograph

Briarwood Mall

S S

tate

St

A2 Endodontics

94

94

94

Lohr Rd

E Eisenhower Pkwy W Eisenhower Pkwy

E Eisenhower Pkwy

Ann Arbor-S

aline Rd

S M

ain St

23

X-ray emailed

Please call me

Evaluate and treat

Evaluate for possible retreatment or apical surgery