This page is for practices referring patients to Westside Endodontics. Please use this form to send us your patient’s information. If you have any questions about this form, do not hesitate to contact us directly at  (403) 457-8400 or email us at prior to submitting the form.

*Please advise patients: NO analgesics 6 hours prior to consultation please.

Patient Information

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Contact Information

Preferred Contact Method

Patient Email

Patient Phone (home)

Patient Phone (mobile)

Referral Information

Referring Dr. Name *

Referring Dentist's Email *

Tooth/Teeth Number(s)

Check all that apply:

Diagnostic Consultation OnlyDiagnostic Consultation & TreatmentEmergency Treatment (Patient in Pain)Intentional Endodontics (Prior to Prosthodontic Treatment)Tooth has prior Endodontic TreatmentX-ray Revealed Apical lesion/open apex/anomalyTreatment Started but Not Completed (calcified/exeptional, anatomy, instrument separation, perforation)Tooth Opened for DrainageProvide Post SpaceCall Doctor prior to Consultation

Other Considerations

Files & Images

Acceptable File Types: JPG. JPEG, PNG, GIF or PDF - Max Per Image Size (10 Mb)

*Note: If uploading numerous files, this form may take a few minutes to submit. Please wait till you have the success confirmation message. Form Submission sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.