Patient Referral

Dr Omar Ikram

Specialist in Endodontics
BDS (Otago NZ), FRACDS, MClinDent (Lond), MRD (Edin), FICD, FPFA

PATIENT NAME:

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Home Phone:

Work Phone:

Mobile Phone:

Relevant Medical History:

Radiographs enclosed?

YES NO

Referred by:

Address:

Tooth Number:

Consultation only Consultation and Treatment

Case Details:

Routine Cracked Tooth Failed RCT - Silver points - Post - Crown Broken Instrument Calcified Canals Perforation Apical Surgery Resorption Traumatic Injury

Clinical Notes:

Attach X-Rays

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Specialist Endo Crows Nest | Suite 301, Level 3, 34 Hume Street, Crows Nest NSW 2065
Ph: 02 9129 0009 [email protected]

specialistendo.com.au

Your Trusted Sydney Endodontist

Gentle, stress-free endodontic care in Sydney—whether it’s root canal therapy or specialist treatment, we’re here to save your natural teeth and keep you comfortable.

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Level 3, Suite 301/34 Hume St, Crows Nest NSW 2065
[email protected]
(02) 9129 0009

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