Brett R. Potter, DMD Norman M. Sawyer, DDS, MS … · Brett R. Potter, DMD Norman M. Sawyer, DDS, MS Peter M. Spradling, DMD Reason for referral: Patient has pain, swelling, sensitivity

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Name________________________________

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Appointment Date _____________________

Pt Phone _____________________________

Phone _______________________________

Time ________________________________

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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 _________________________________________________________________

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