Referral Form - Bay Ridge Endo: Modern Endodontics Dental Office

718-745-4200
615 Bay Ridge Pkwy, Brooklyn, NY 11209
Monday - Thursday 09:00 - 17:00

Procedures
About us
- Our Team
- Contact us
Referring Doctors
- Referral Form
Patient Information

Procedures
About us
- Our Team
- Contact us
Referring Doctors
- Referral Form
Patient Information

Doctor e-Referral Form

Working in close partnership with our referring doctors is an important aspect of the care we provide. We value each and every referral and take great pride in providing a warm, comfortable and technologically advanced environment. Our friendly staff is here to assist you when you need us.

Please call us at 718-745-4200

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Choose the Specialist *

Dr. Giovanni Ippolito
Dr. Alexandra Vakopoulou
Dr. Raven Drummond
First Available

Patient's Name for Endodontic Consideration *

First

Last

Patient's Email *

Referring Doctor's Name *

First

Last

Front Desk Email *

Referring Office Phone *

Tooth Number *

Status of the tooth in question: *

Pulp was Exposed
X-ray revealed Pulpal Involvement
X-ray revealed Radiolucency
Patient in Pain
Prior Endo Tx Questionable
Suspect Fractured Tooth
Intentional Endodontics
Consider Surgical Endodontics
Recent Crown/Restoration
Analgesic/ Abx Prescribed
Please Leave Post Space
Please Restore Access
CBCT
Crown Planned for Replacement

Remarks

Add Radiograph(s) (Max: 500 MB)

Click or drag files to this area to upload. You can upload up to 5 files.

Bay Ridge Endodontics

615 Bay Ridge Pkwy, Brooklyn, NY 11209

Tel: 718-745-4200

Request an Appointment today and we promise to help you with every issue you may have.

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