Coral Gables, FL

Referrals


If you are a doctor looking to refer a patient to us, please click the link below to download our PDF referral form or fill out our online referral form.

PDF Referral Form



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Online Referral Form


Today's Date:*
Introducing:*
Patient's Phone (H):*
(Work or Cell Phone):*
Referred By Doctor:*
Doctor's Phone:*
Upper Tooth Numbers (Check all that apply)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Lower Tooth Numbers (Check all that apply)
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Appointment Arrangements
Patient will call to make an appointment
An appointment has been made
Call Patient to make an appointment
If an appointment has already been made, please list the day and time here:
Reason for Referral
Consultation and Diagnosis
Root Canal Therapy
Retreatment of Root Canal
Apicoectomy/Retrograde
Post Space Preparation
Internal Bleaching
CBCT with Radiology Report
CBCT without Radiology report
Post Removal
Incision and Drainage
Place Post and Core
Place Core Only
Other
If "other," please elaborate:
Special Instructions
Please write out any special instructions:
Please enter the text you see:

Location
550 Biltmore Way, Penthouse 3B
Coral Gables, FL 33134

Hours
Monday - Thursday: 8:30am - 5pm
Friday 8:30am - 3:00pm

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Endodontix Dental Group - Anthony Alonso Jr. , DMD | www.endodontix.com | 305-447-4000
550 Biltmore Way, Penthouse 3B, Coral Gables, FL 33134