Vista Endodontics & Periodontics - North Raleigh

Referring Practice Name*
First Name**
Last Name**
Email*
Phone Number**
Format: +1 (000) 000-0000.
First Name**
Last Name**
Email**
Phone Number**
Format: +1 (000) 000-0000.
Date of Birth*
Parent/Guardian
Insurance Subscriber ID/Member ID*
Preferred Location*
Type a question
Reason for Referral:
ConsultationRoot Canal TherapyRoot Canal RetreatmentPost SpaceCBCTOral SedationOther
Medical History
Premed NeededAnticoagulants (Warfarin, Coumadin)Bisphosphonates TakenOther
Type a question*
Prior Treatment
No Treatment Involving PulpPulpotomy or PulpectomyPulp Exposure and CapPrevious Endodontic Treatment or Surgery
Restore Access With
TemporaryComposite
X-Ray Status
Please Take & Send CopyCopy Given to PatientX-rays Enclosed/EmailedNone Provided
File Upload

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I have files larger than 35MB. Please contact me directly to receive them
Large File Condition
Note: Please email x-rays to NREP@VistaDP.com
Additional Helpful Information:
Please call to set up patient’s appointment or we will contact the patient within two business days after receiving this form.
"Please evaluate teeth for" Condition
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