Periodontal and Implant Referral Form

DATE:*

PATIENT NAME:*

PHONE NO:*

PATIENT E-MAIL:

DOCTOR NAME:*

First

PHONE NO:*

PATIENT REFERRAL TO

CONTROL-CLICK (WINDOWS) OR COMMAND-CLICK (MAC) TO SELECT MORE THAN ONE.

REASON FOR REFERRAL

TOOTH #(S):

QUADS:

Has the patient had previous periodontal therapy?

Have you advised the patient of the possibility of extraction of any teeth?

IF YES WHICH TEETH?:

Does the patient require premedication?

ANTIBIOTIC USED:

Does the patient have pending treatment with your office?

NOTES:

RADIOGRAPHS:

UPLOAD X-RAY IMAGES:

Accepted file types: jpg, gif, png, bmp, tiff, png, pdf, doc, docx, Max. file size: 50 MB.

Must be a common image file type: .jpg, .gif, .png, .bmp, .tiff, .png, .pdf, word document.

ADDITIONAL COMMENTS:

PLEASE:

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