Doctor's Name No preferenceJames F. Gianakakis, D.D.S, M.S.Jeffrey H. Hembrough, D.D.S., M.S.Mark S. Palo, D.D.S., M.S.Vince A. Penesis, D.D.S.Benjamin J. Schwabe, D.D.S.Jordan R. Simonovich, D.M.D., M.S. Patient's Name Patient's Phone Number Tooth Number 12345678 910111213141516 3231302928272625 2423222120191817 Treatment Plan Endodontic TherapyElective Endodontic Therapy Consultation Only Endodontic TherapyRetreatmentSurgery Vitality VitalityNon-vitalNon-vital with periapical lesion Post Room YesNo Clinical Findings SymptomaticOpen apexCalcified Canal(s)Sinus tractResorptionSeparated instrumentPulpotomy or Pulpectomy completed Premedication Required YesNo Upload X-Ray image Special instructions/Comments Referred by: Phone Number
