Please upload relevant digital x-rays
History of presenting complaint:
Relevant medical history:
Treatment requested (please tick all that apply)
Opinion onlyPrimary root treatmentRe-treatmentEmergency extirpationRestorability assessmentPost removalInstrument removalSurgical endodonticsOther
The endodontic access will be sealed with a permanent core of amalgam or composite. If there is a preference; please specify below.
No preferenceCompositeAmalgamGlass IonomerPost and core
Referring dentist name
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