Doctor Referral Form

Our referring offices send their patients to us to have root canal treatment and other endodontic services performed by our experienced staff. Once we have finished the procedure, the patient will return to their referring general dentist to have permanent restoration completed.


To Refer A Patient, Please Fill Out The Form Below

  • MM slash DD slash YYYY
  • For Endodontic Consideration

  • HH Hancock III Root Canal Endodontist in Raleigh NC -
  • Please enter a number corresponding with the diagram above. For more than one selection, separate tooth numbers with commas.
  • Radiographs

  • Drop files here or
    Max. file size: 50 MB, Max. files: 5.
      If you have digital copies of the patient's x-rays, you may upload them here.
    • MM slash DD slash YYYY
    • :