824 N. Main St. Suite A
Roswell, NM 88201
www.carabellidental.com
(575) 622-4455
Demographic Information
Patient Information
Name
Date of Birth
Parent/ Guardian name (if under 18)
Patient Phone Number
Patient Email Address
Referring Information
Referring Doctor Information
Referring Doctor
Office Name
Office Phone Number
Referred For
Wisdom Teeth Removal
Yes
No
Extractions
Yes
No
Implant
Yes
No
IV Sedation
Yes
No
Comprehensive Exam
Yes
No
Crown / Bridge
Yes
No
Snoring Device / Sleep Apnea
Yes
No
Expose & Bond
Yes
No
Root Canal Treatments
(Without IV Sedation only)
Diagnosis
Retreat
Yes
No
Complete Core Buildup
Yes
No
Complete Buildup and Crown
Yes
No
Please submit PA of each tooth needing RCT Treatment and list diagnosis
Tooth Chart
Tooth Chart
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Instructions