Refer a Patient

Are you interested in referring a patient to Elite Endodontics? Dr. Lisa, Dr. Kushnir and our team are proud to have earned your trust, and we will do everything in our power to exceed your expectations regarding the quality of care we provide to your patient. Below, referring dentists can complete our form with all of the necessary information and print it for convenience’s sake. Please contact us here in Westerville, OH if you have any questions or concerns.

Patient Being Referred

Patient Phone Number

Patient Email

Tooth or Area of Mouth to be Evaluated

Medications Prescribed by Referrer

Symptoms or Findings

Pain, swelling or sensitivity Radiograph reveals pathology Previous root canal therapy – please indicate type of obturation material if known and if a post is present

Services Requested

Evaluation Root Canal Therapy Post Space Preparation Retreatment evaluation Evaluation for an apicoectomy

Referring Dentist

Practice Name

Practice Phone

Practice Email

Other Information