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info@olympicendo.com
(720) 340-1796

REFERRING DOCTORS

REFERRING DOCTORS

REFERRAL FORM

Attach Radiograph(Required)

Max. file size: 32 MB.

Additional Information (E.g. tooth was recently restored, restorative plan, specific concerns)

Does the patient need oral sedation and/or nitrous oxide?(Required)

Halcion- (The patient will need a consultation with the endodontist first before scheduling treatment. At the consultation appointment, the endodontist will determine whether they're a good candidate for the medicine and we will prescribe it to them).

Nitrous Oxide

Endodontic Procedure Requested(Required)

Evaluate and Treat as Necessary

Evaluate Only/Consult Doctor Before Proceeding

Leave Post Space

Place Build Up/Access Filling

Status of Tooth(Required)

Symptomatic

Previously Accessed

Suspected Cracked Tooth

Asymptomatic

Previously Root Canal Treated

Tooth Number/ Teeth Numbers(Required)

Referring Office Email

Referring Doctor Office/Phone No(Required)

Referring Doctor Name(Required)

Patient Email

Patient Phone No(Required)

Patients Name(Required)

First Last

Select Office(Required)

Colorado Springs

Aurora

Pueblo

Lakewood

Falcon

Fountain

Referring Doctor Form

Select Office

Colorado Springs

Aurora

Pueblo

Lakewood

Falcon

Fountain

Select Nearest Office in Colorado Springs

Select Nearest Office in Fountain

You've Selected North Powers Modern Dentistry as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-380-0141

You've Selected Dentists of Centennial and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-867-4025

You've Selected Dentists of Broadmoor as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-249-8775

You've Selected Prominent Point Dental Group and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-495-5748

You've Selected Dentists of Interquest and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-867-4291

We've Aurora Village Dental Group as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 303-595-5454

We've Crestline Dental Group and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 303-979-4277

We've Dentists of Falcon and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-323-6734

We've Pueblo Modern Dentistry and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-542-4000

You've Selected Cheyenne Mountain Modern Dentistry and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-392-5354

You've Selected Fountain Modern Dentistry and Orthodontics as your nearest Office.

Dr Dijana Elmejdoubi, Endodontist,DDS, MS
Call : 719-382-4936

Patient's First Name

Patient's Last Name

Patient Phone No

Patient Email

Referring Doctor Name

Referring Doctor Office/Phone No

Referring Office Email

Tooth Number/ Teeth Numbers

Status of Tooth

Symptomatic

Previously Accessed

Suspected Cracked Tooth

Asymptomatic

Previously Root Canal Treated

Endodontic Procedure Requested

Evaluate and Treat as Necessary

Evaluate Only/Consult Doctor Before Proceeding

Leave Post Space

Place Build Up/Access Filling

Does the patient need oral sedation and/or nitrous oxide?

Halcion- (The patient will need a consultation with the endodontist first before scheduling treatment. At the consultation appointment, the endodontist will determine whether they're a good candidate for the medicine and we will prescribe it to them).

Nitrous Oxide

Additional Information (E.g. tooth was recently restored, restorative plan, specific concerns)

Attach Radiograph

Upload Radiograph

You can also download our Referral Form

OLYMPIC ENDO

At Olympic Endo, we specialize in professional root canal treatments, offering precise and effective solutions to preserve your natural teeth. Our experienced endodontists in Colorado use advanced technology to ensure comfortable, high-quality care tailored to your needs. Dedicated to excellence, we focus on restoring your dental health and relieving pain. Trust us for compassionate, expert care in a welcoming environment.

OFFICE HOURS

Mon.	8:00AM – 5:00PM
Tues.	8:00AM – 5:00PM
Wed.	8:00AM – 5:00PM
Thurs.	8:00AM – 5:00PM
Fri.	8:00AM – 5:00PM
Sat.	8:00AM – 5:00PM
Sun.	Closed

Our services

Root Canal Treatment

Root Canal Retreatment

Endodontic Surgery

Treatment for Children

Traumatic Dental Injury

© 2026 Olympic Endo

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