Referral Form

Doctors at Endodontics Associates of Georgia

Damaries Candelario-Soto, DMD, MPH, Janina Adelaida Figueroa, DMD, MPH, Joseph Yoo, DMD, Shaletha Bolden, DDS, Yasir Al-Drugh, DDS

Participating Providers For:

Aetna/Aetna DMO
BCBS Grid/Grid Plus
Cigna
Cigna DHMO

Decare
Delta Dental
Dental Health Alliance
Dental Benefits Provider

Dentegra
GEHA Connection
Guardian
Humana

MAVREST
MetLife
United Concordia
United Healthcare

Patients Name *

Email *

Phone *

Practice / Location

Referring Dr. Phone Number

Referring Dr.

Date

mouth layout using teeth diagram

Cone Beam CT Scan

Maxilla

Mandible

Maxilla and Mandible

TMJ

Sinus

Treatment Desired

Evaluation Only

Nonsurgical RCT

Pretreatment

Surgical RCT

Post Space

Post Placement

Restore Access With

Temporary

Composite

Amalgam

Comments *

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Referral Form