San Marcos Form:

Office:
Date:
Patient Name:
Referring Doctor:
TREATEMENT TO BE PERFORMED:
Consultation Only
Periapical radiolucency present
Pulp exposure
RCT required for proper restoration
Evaluation for endodontic surgery
Root canal therapy
RESTORATIVE INSTRUCTIONS:
Place post and build-up
Leave post space
Place temp in access cavity
Place final restoration in access cavity
TOOTH TO BE EVALUATED:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
MISCELLANEOUS:
Call me about this case
Crown and bridge is cemented
Temporarily      Permanently
SPECIAL INSTRUCTIONS: