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Pinehurst Endodontics
James R. Corcoran, DDS
(910) 295-9950 | (919)775-3636 | Fax (910)295-5076
91 Aviemore Drive | Pinehurst, NC 28374
Pt:
DOB:
Date:
For an appointment at:
AM /
PM
on
20
TEETH FOR ENDODONTIC CONSIDERATION
Molars
Bicuspids
Anteriors
Bicuspids
Molars
R
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
L
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Evaluate only
Define treatment
Periapical radiolucency
Patient has vauge toothache
Crown temporarily cemented
Pulp exposure
Make post space(s)
Place composite filling
Place amalgam filling
COMMENTS:
REFERRED BY:
PHONE:
Patient will be instructed to return to referring Dentist for final restoration
PLEASE BRING TO APPOINTMENT
