Referring Doctors

Date:

Patient Name:

Patient Phone (Home):

Patient Phone (Work/Cell):

Referred by Dr.:

Office Phone:

Office Email:

Complete periodontal examination: DDS sending FMXTake FMX and send me a copy

Sedation: YesNo

Muco-gingival problem (Tooth #):

Gingival graft: Root coverageFrenectomy

Crown lengthening (Tooth #):

Osseo-integrated implant (Tooth #):

Preferred implant system:

Ancillary Implant Therapy (Tooth #):

Site Development: Sinus floor elevationRidge augmentationGuided implant surgery

Regenerative Therapy (Tooth #):

Pocket elimination procedures (Tooth #):

Gingivectomy/gingivoplasty: Resective osseous surgery

Impacted Third Molar/Tooth Extraction: YesNo

Alveoplasty: YesNo

Biopsy: YesNo

Emergency care (Tooth #):

Periodontal abscess: Acute necrotizing ulcerative gingivitis

Peri-Implant Disease: YesNo

Oroantral Communication: YesNo

Other:

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