Date_________________________________

Name________________________________

Referred by ___________________________

Appointment Date _____________________

Pt Phone _____________________________

Phone _______________________________

Time ________________________________

www.victoriatxendo.com

Brett R. Potter, DMD Norman M. Sawyer, DDS, MS Peter M. Spradling, DMD

Reason for referral:

❏ Patient has pain, swelling, sensitivity ❏ Tooth has been previously opened ❏ Medical health alert ❏ Other _________________________________________________________________

Treatment requested:

❏ Exam ❏ Treatment ❏ Place post and core ❏ Prepare post space only ❏ Repair Access with: ❏ Composite ❏ Alloy ❏ Temporary ❏ Other _________________________________________________________________

Comments _________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

103 Professional Park Drive • Victoria, TX 77904-2351361-576-1235 • Fax 361-573-4113