Brett R. Potter, DMD Norman M. Sawyer, DDS, MS … · Brett R. Potter, DMD Norman M. Sawyer, DDS,...
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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 77904-2351 361-576-1235 • Fax 361-573-4113
Transcript of Brett R. Potter, DMD Norman M. Sawyer, DDS, MS … · Brett R. Potter, DMD Norman M. Sawyer, DDS,...
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
