Printable referral worksheet
The worksheet below can be completed in the browser and printed. It is not submitted or stored by this website. Call KC Endodontics before sending the completed document or any clinical records so the office can confirm the current secure delivery method.
Download the fillable referral PDF
Protect patient information
Do not transmit protected patient information through ordinary, unsecured email or an unapproved web form. Before sending records electronically, call KC Endodontics to confirm the practice’s current secure process.
Office contact
- Phone: 913-642-3636
- Fax: 913-642-5066
- Address: 3700 W. 83rd Street, Suite 106, Prairie Village, KS 66208
For time-sensitive referrals, pain, swelling, or dental trauma, please call rather than relying on a document alone.
Helpful referral details
Including the following can reduce back-and-forth and help the patient’s first visit proceed smoothly:
- The tooth or area of concern
- The reason for the referral
- Relevant treatment history
- Recent images
- Restorative plans or limitations
- Preferred treatment scope
- Best contact information for follow-up