We appreciate the confidence you place in our practice by referring patients to us for endodontic care. You may refer a patient by:

  • Calling 251-626-8480, Monday – Thursday, 8:00 am – 5:00 pm, closed 12:30 – 1:30 pm
  • E-mailing . A referral form may be downloaded by clicking on the icon below or by filling out the online form below. You may send a digital X-ray or scan and send a traditional X-ray, as well as a description of a case you would like to discuss with Dr. Manasco, to this e-mail address.
  • Mailing to:
    Eastern Shore Endodontics,
    27695 U.S. Highway 98,
    Daphne, AL 36526

Referral Form

If you have a referral, please fill out the form below:

* denotes required field

* Patient Name:
Endodontic Treatment for Tooth #:
Sensitive to: Pressure Hot Cold
Symptoms: Swelling Fistula Sinus Tract
Crown or Bridge Cemented:

Temporarily
Permanently

Tooth will need to be:
We have prescribed:
Remarks
Upload X-Rays:
* Referring Doctor:
* Referring Doctor Email:
 

 

Gentle & Compassionate Endodontic Care

Our Location

27695 US Highway 98
Daphne, AL 36526-4816
P: (251) 626-8480

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