HomePeriodontal and Implant Referral Form
Patient Name: *
Phone No: *
Doctor Name: *
Patient Referral To
Dr. Alan PomeranzDr. Emilio ArguelloDr. Neil NeugeborenDr. MarcuschamerDr. Hong
Control-click (Windows) or command-click (Mac) to select more than one.
Reason for Referral
---Comprehensive Periodontal EvaluationBone Graft / regenerationImplant EvaluationOsseous SurgerCrown LengtheningGingivectomySoft Tissue GraftsFrenectomyEmergency Evaluation (problem focused)Other
Has the patient had previous periodontal therapy?
NoneProphylaxis OnlyAntimicrobial TherapyScaling and Root PlanningSurgery
Have you advised the patient of the possibility of extraction of any teeth?
YesNo If yes which teeth?:
Does the patient require premedication
YesNo Antibiotic used:
Does the patient have pending treatment with your office
RADIOGRAPHS: Please take/send copyPatient will bring copyI will send / Please return
UPLOAD X-RAY IMAGES:
Must be a common image file type: .jpg, .gif, .png, .bmp, .tiff, .png, .pdf, word document.
Call me before seeing the patientCall me after seeing the patientAlternate recare appointmentsDo all recall care after patient is treatedSend me reportGeneral Dentist signature:Call patient to schedule
Schedule a consult today and we will create a treatment plan customized for your needs.