Please leave this field empty.
Your Name
Date of Birth
Parent / Guardian
Contact Telephone
Contact Email
Does the patient require antibiotics prior to dental treatment?
YesNo
Please call patient
Treatment
Referred By
Telephone
Email
Complete Periodontal Evaluation
YesNo EarlyModerateAdvanced
Implants
YesNo ImmediateDelayed
Crown Lengthening
Ridge Augmentation
Gingival Contouring for Cosmetics
Guided Tissue Regeneration
Extraction
Other:
Have you advised the patient of the possibility of extraction?
TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SELECT THE "Complete and Send" BUTTON BELOW. AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.
Radiograph / Clinical Photo
Being MailedGiven To PatientPlease TakeNo X-RayAttached with this Referral
If X-Rays are attached, what date were they taken:
Plaque Control Instruction
Prophylaxis and Gross Scaling
Root Planing
Periodontal Maintenance Therapy
Restorative Comments
