Coral Gables, FL

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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

•	Referral Form (PDF)

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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:

Referring Doctors
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Maps & Directions

Location
550 Biltmore Way, Penthouse 3B
Coral Gables, FL 33134-5730

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

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