Create a referral
Powered by
Foothill Endodontics
3534 Lone Pine Road
+1 (541) 200-0321
Dr. Bryce Taylor
*
Required Field
PROVIDERS
From
Office/Business Name
The organization sending this referral
Referring Provider First Name ("Dr." added automatically)
*
Referring Provider Last Name
*
Office Email
*
Office Phone Number
Information for the provider sending this referral
To
Organization, Provider or Email Address
*
The organization receiving this referral
Location Preference
You can select a maximum of 3 locations
Provider Preference
You can select a maximum of 3 providers
Choose up to 3 preferred providers or locations (optional)
PATIENT
First Name
*
Last Name
*
Phone Number
*
Email Address
Date of Birth
*
Insurance
Member ID
Group Number
DETAILS
Describe the consult or desired treatment.
*
Urgent
If unchecked, this referral will be considered routine.
Location Confirmation (optional)
a
b
c
d
e
f
g
h
i
j
t
s
r
q
p
o
n
m
l
k
Additional Information
Primary Insured if different than the patient
Primary Insured Birthdate
Endodontics Information
Appointment request type
Consultation Only
Treatment as indicated
History
Previous Endodontic treatment
History of trauma
Pulp exposure
Access restoration request
Temporary
Permanent
Post/Core
Build Up
Post Space
Leave post space
Yes
No
Attachments (Optional)
Upload
Upload up to 5 files
Files supported: .DICOM, .jpeg and .pdf
Max size per file: 125MB
Include radiographs, if possible
Send Referral
Are you sure you want to send this referral without images?
No, hold on
Yes, send
By continuing, I agree to Sindi’s
Terms & Conditions
,
BAA
and
Privacy Policy
Enter your one-time password
to submit the referral
A one-time password has been sent to
If you do not see a verification email in your inbox, please check your spam/junk and mark
noreply@sindireferrals.com
as
not spam
to receive future updates on the referral.
Validate