truForm by PBHS

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Patient Information
Doctor Information
Referred for
Other Information
Radiographs
Remarks

Main Header

Patient Information

Name

First Name

Last Name

Phone

Home phone

Office phone

Doctor Information

Referring Doctor Information

Referred by

Telephone

For consideration for consultation and/or Endodontic treatment.
Please indicate tooth/area to evaluate below:

Please indicate

Referred for

Referred for the following

Consultation & Diagnosis

Root Canal Treatment

Re-Treatment

Leave Post Space

Apicoectomy / Retrograde

Pulp Exposure

Remove Post

Other Information

Please send additional referral pads

Please call patient to arrange appointment

Patient will call you to arrange appointment

Crown / Bridge is Cemented:

Temporarily Permanent

Please Call Me

Radiographs

Being Sent w/Referral Form Given to Patient

TO ATTACH X-RAY(S)TO THIS REFERRAL FORM PLEASE SUBMIT THE FORM AND FOLLOW INSTRUCTIONS ON THE FOLLOWING PAGE TO SUBMIT UP TO 5 X-RAYS.

Please Mark Teeth or Area to be Treated

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
RIGHT	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17	LEFT

Remarks

Remarks or Special Instructions

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

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Review your signature

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By clicking accept and sign, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office – in just the same way as a pen-and-paper signature.

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Our records show you have previously submitted one or more truForms. Would you like to populate the answers from a previous submission onto this form? If so, please select the desired submission from the list below, then click 'Confirm'. Please note that you will have the ability to review and change any answers before submitting this form.

Name	Date Submitted

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Main Header

Patient Information

Patient Information

Doctor Information

Referring Doctor Information

Referred for

Referred for the following

Other Information

Other Information

Radiographs

Radiographs

Please Mark Teeth or Area to be Treated

Remarks

Remarks or Special Instructions

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.