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PATIENT REFERRAL FORM
TRUSTED BY PATIENTS AND DENTISTS FOR OVER 50 YEARS

PATIENT REFERRAL INFORMATION

Patient Name

Date of Birth

Patient Contact Information

Practice Information

OUR DOCTORS:

Yuri Shamritsky, DMD, DDS

Fiza Singh, DDS, MMSc, FRCD(c)

Paul B Talkov, DMD, CAGS

OUR LOCATIONS:

Brookline Office
One Brookline Place,
Ste 505
Brookline, MA 02445
(617) 735-8500

Newburyport Office
3 Cherry Street
Newburyport, MA 01950
(978) 462-9200

Peabody Office
6 Essex Center Drive,
Ste 110
Peabody, MA 01960
(978) 532-0500

Gloucester Office
321 Washington Street
Gloucester, MA 01930
(978) 281-2512

Lynn Office
60 Lewis Street
Lynn, MA 01902
(781) 599-1100

Beverly Office
900 Cummings Center,
Ste 121V
Beverly, MA 01915
(978) 921-1039

Appointment Information

Appointment Date

Doctor

Appointment Time

Location

REFERRING DOCTOR

Remarks

Referrer Name

Welcome

TRUSTED BY PATIENTS AND DENTISTS FOR OVER 50 YEARS

Welcome to North Shore & Brookline Endodontics (NSBENDO).

We consider it a privilege when dentists refer their patients to our practice. We honor this trust by providing you with prompt attention, high-quality care, and most of all, respect.

Your dentist has referred you to our practice because we can help save your tooth and alleviate your pain. Our doctors have the knowledge, experience, and technology to achieve the best possible outcome and to make it an anxiety-free procedure.

Why an Endodontist?

SPECIALISTS IN SAVING TEETH

Endodontist are dental specialists who save teeth from extraction by performing root canal therapy. Deep within the tooth lays an intricate network of nerve fibers and small blood vessels. Progressive tooth decay, cracks, or trauma can cause this tissue to become inflamed or infected. This condition is usually painful, and it can quickly threaten the tooth. Root canal (endodontic) therapy is the alternative to removing the tooth, which can make chewing difficult and cause unwanted changes to your smile.

Our endodontists accomplish root canal therapy in one or two visits. Our doctors will administer local anesthetics so that you remain comfortable throughout the procedure. Once you are comfortable, we will clean, shape, and seal the root canal space. When your treatment is complete, we will automatically forward a report to your dentist’s office where you will return for a placement of a permanent filling or crown. This teamwork between our doctors and your dentist will ultimately result in bringing your tooth back to its normal appearance and function.

Your Visit

USEFUL INFORMATION

Our goal is to make your visit as pleasant and efficient as possible. Please call our office and a scheduling coordinator will book an appointment for a consultation, an emergency visit, or a routine treatment visit, whatever is best suited to your particular needs.

Prior to treatment, all patients and parents of minors are required to complete a medical history form. This form is available on our website, www.nsbendo.com/patient-info. Please complete the form and print it out or submit it electronically ahead of time. Besides this information, we ask that you bring to your first appointment a list of all medications you are taking. If you’ve been advised by your physician or dentist to use antibiotic pre-mediation for mitral valve prolapse, heart murmur, joint or cardiac prosthesis, or if you have rheumatic heart disease, please be sure to follow all premedication instructions prior to your visit.

If you have dental insurance, our office staff will gladly confirm your coverage, advise you of your estimated benefits, and inform you of an estimated co-pay amount. Following your treatment, we will complete and submit the appropriate forms to your insurance company to achieve the maximum reimbursement to which you are entitled. Your estimated copay, as well as payment for any procedures not covered by your insurance, is expected to be paid at the time of treatment.

Please call us at any time if you have questions or concerns. Detailed information about your procedure is also available on our website: WWW.NSBENDO.COM

About NSBENDO

PRECISE DIAGNOSIS, FASTER TREATMENT

For over 50 years, our reputation for clinical skill and professionalism has let trusted local dentists to refer their patients to our practice. We work in an environment that exceeds the high standards of sterilization and cleanliness advocated by the American Dental Associates, the CDC, and OSHA.

NBSENDO IS PROUD TO FEATURE:

• Electronic Health Records (EHR), which streamlines communication and provides better security.
• Magnifying telescopes and surgical microscopes that allow our doctors to correct previously undetectable problems, thereby greatly improving the likelihood of a successful outcome.
• The latest in digital x-rays, which provide an 80% reduction in radiation exposure compared to standard dental film.
• Instant image viewing, allowing immediate analysis of your case and better illustration when we explain your prognosis and treatment plan.
• 3D Cone-Beam CT Imaging improving diagnostic speed, accuracy, and ultimately, outcome.
• Secure Email and Secure Contact to protect patient information.
• Sedation dentistry for those who experience dental anxiety.

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Demographic Information

PATIENT REFERRAL INFORMATION

Referring Information

Tooth Number

Referred for the Following

Appointment Information

Practice Information

Appointment Information

Referring Doctor Information

REFERRING DOCTOR

Welcome

Why an Endodontist?

Your Visit

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Main Header

Demographic Information

PATIENT REFERRAL INFORMATION

Referring Information

Tooth Number

Referred for the Following

Appointment Information

Practice Information

Appointment Information

Referring Doctor Information

REFERRING DOCTOR

Welcome

Why an Endodontist?

Your Visit

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You are in Private Browsing mode.

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