Level 3, Suite 301, 10 Help Street, Chatswood NSW 2067 T: 02 9411 3003 F: 02 9411 1006 Level 3, Suite 21, 27 Hunter Street, Parramatta NSW 2150 T: 02 9891 1610 F: 02 9891 1831 Level 1, Kiaora Place, 451 New South Head Rd, Double Bay NSW 2028 T: 02 9326 1399 F: 02 9411 1006 Date / / Email address: TREATMENT: Consultation/Prognosis Endodontic Treatment Diagnosis of Pain Endodontic Re-treatment Post Removal Intravenous Sedation Cracked Tooth TOOTH: POST SPACE REQUIRED? Yes No CORE RESTORATION REQUIRED? Yes No NOTES: 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Trauma Management Periapical Surgery Perforation Repair Non-Vital Bleaching Internal/External Resorption Other: SPECIALIST ENDODONTIST Dr Mark Johnstone Dental Specialist - Endodontist BDSc(Hons), DClinDent, MHth&MedLaw Dr Mehdi Rahimi Dental Specialist - Endodontist Adjunct Associate Professor (CSU) BSc, BDS Distinction (NZ) DClinDent (Melb), FICD, FPFA, MRACDS Referred by Dr: Address: Phone: Dr Martin M Habibi First Available Specialist Endodontist Dr Garima Sharma Dental Specialist - Endodontist BDS, DClinDent (Adelaide) Dr Chankhrit Sathorn Dental Specialist - Endodontist Adjunct Professor (CSU) DDS, GradDipClinDent, DClinDent, PhD (Melb), MRACDS (Endo) Dental Specialist - Endodontist DDS, DClinDent (UWA) MRACDS (Endo) Dr Langley Tasmania Dental Specialist - Endodontist BDS (Fiji), DClinDent (Otago) [email protected]