Form

Western Carolina Family Dentistry

Matthew Beauchemin, DMD
505 Realty Street SW Lenoir, NC 28645
Phone Number: (828) 754 - 2600
Email: referral.wcfdentistry@gmail.com

Date

Referring Office Name:

Referring Office Phone Number:

Patient First Name

Patient Last Name

Date Of Birth

Phone Number

Medicaid Number

Please Select One:

Please select tooth number to be root canal treated:

Please verify tooth/teeth numbers to be root canal treated:

Please upload x-rays here:

Upload or drag files here

Date of when x-ray was taken:

Important Notes:

** Our office performs molar, premolar, and anterior root canal treatment on maxillary and mandibular teeth.

** Our office does not perform root canal treatment on children under the age of 10 UNLESS it’s an anterior tooth.

** Our office does not perform root canal treatment on anyone over the age of 20.

** We perform root canal treatment the day the appointment is set up for. If you are wanting only a consult make sure to clarify when setting up the appointment.

** Our office does not offer nitrous oxide (laughing gas). We only offer local anesthetic.

** It the patient misses or cancels the day of we will not reschedule the appointment and patient will need to call the referring dentist office.

** Our office does not perform retreats on previously root canal treated teeth.