Patient Details
Address
Preferred Contact Number
Clinical details
Please click a tooth number below and enter the details for each tooth or type your own referral reason in the box below.
document.addEventListener('DOMContentLoaded', function() {
const toothNumbers = document.querySelectorAll('.tooth-number');
const selectedNumbersField = document.querySelector('textarea[name="selected-numbers"]');
toothNumbers.forEach(function(tooth) {
tooth.addEventListener('click', function(event) {
event.preventDefault();
const number = this.getAttribute('data-number');
const currentValue = selectedNumbersField.value;
selectedNumbersField.value = currentValue ? currentValue + '\n' + number + '-' : number + '-';
});
});
});
Pre-operative signs & symptoms
Current Status
Restorative Requirements
Preferred Endodontist
Referral by
Contact Details
