Doctor Referral Form Doctor Referral Patient Name * Treating Doctor * First Available Jin Hahn, DMD Jeffrey Chen, DMD Jason Yoo, DDS Type of Treatment * Consultation only CBCT Consult only Treatment of tooth Treatment of Tooth Procedures * Root canal Retreatment Apicoectomy/Retrograde Endodontics necessary for proper restoration Patient has pain, sensitivity or swelling X-ray reveals radiolucency Remove post Please call me Select all that apply. Tooth # * Will you need a post space? * Yes No Radiographs will be: * Uploaded here Emailed Mailed Patient will bring x-rays Upload 1 Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 516MB Upload 2 Drop a file here or click to upload Choose File Maximum upload size: 516MB Referring Doctor * Comments * Email * reCAPTCHA Submit