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Referring Doctors

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Referral form

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Practice

Medical practice

Dentist

Street, no.

Phone

ZIP code, city

E-mail

Patient

Surname, first name

Date of birth

Street, no.

Phone

ZIP code, city

E-mail

Coverage

Self-coverage
Insurance (Accident, UVG / Disability, IV / Military, MV)
Basic Health Insurance (KVG)
Supplementary Benefits (to AHV/IV)
Other:

Other *

Desired treatment

Tooth/Teeth/Region

Transfer for

Diagnostics/consulting
Microsurgical apicoectomy
Root canal treatment
3D imaging (DVT)
Root canal treatment revision
Other therapies

Other therapies

Comment on the treatment

Need for treatment *

Normal
Urgent*

*In case of high acute/emergency please also contact us by phone.

Would you like a phone consultation before starting treatment?

Yes
No

Post-endodontic care

Access cavity closure

Situational, when appropriate
Definitive adhesive closure
Temporary closure

Remarks on post-endodontic treatment

Root post insertion

Yes
No
Yes, when appropriate

Transmission of enclosures

For data protection reasons, please send all enclosures, X-ray images etc. via endo-zuerich@sso-hin.ch.

Transmission of enclosures *

by encrypted e-mail
with patient
no enclosures available

Consent for sending forms *

I accept the privacy policy and agree that the data entered will be used for processing and sent as an e-mail confirmation.

PD Dr. Dan-K. Rechenberg (vCard)

Legal & Privacy

Oberdorfstrasse 2
8001 Zürich

+41 (0)44 212 01 11
mail@endo-zuerich.ch
endo-zuerich@sso-hin.ch (encrypted)

Office hours

MO – THUR	8 – 12 13 – 17
FR	8 – 12

Legal & Privacy

Aufgrund der Herbstferien ist die Praxis geschlossen. Ab Montag, dem 21. Oktober sind wir wieder wie gewohnt für Sie da.
Beste Grüsse
das Team von Endo Zürich

Im akuten Notfall kontaktieren Sie bitte den zahnärztlichen Notdienst des Kanton Zürich unter der Telefonnummer:
0800 33 66 55