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Dr. Alan Pomeranz
Dr. Emilio Argüello
Dr. Eduardo Marcuschamer
Dr. Heather Hong
Dr. Neil Neugeboren
Dr. Arthur Yagudayev
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About
Column
Meet the Doctors
Dr. Alan Pomeranz
Dr. Emilio Argüello
Dr. Eduardo Marcuschamer
Dr. Heather Hong
Dr. Neil Neugeboren
Dr. Arthur Yagudayev
Column
Who we are
Tour our Office
Office Philosophy
Career
Services
Column
Dental Implants Services
Types of Dental Implants
Single Tooth Dental Implant
Dental Implant Treatment
All on 4
Implants Before and After
Column
Non-dental implant services
Periodontal Disease
Gum Recession
Osseous Surgery
Bone Grafting
Cosmetic Procedures
Waterlase
Deep Cleanings & Periodontal Maintenance
Other Services
Patients
New Patients
Your First Appointment
Existing Patients
Office Policies
Frequently Asked Questions
Referring offices
Events
Referral Form
Our Study Clubs
News
Articles
Videos
Payment Options
Pay Online
Care Credit
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Periodontal and Implant Referral Form
Referring Offices
Periodontal and Implant Referral Form
Download Printable Referral Form
Thank you for you referral. For us to best serve you and your patients, please fill in the information and submit below. We look forward to working with you!
DATE:
*
MM slash DD slash YYYY
PATIENT NAME:
*
PHONE NO:
*
PATIENT E-MAIL:
DOCTOR NAME:
*
First
PHONE NO:
*
PATIENT REFERRAL TO
Dr. Alan Pomeranz
Dr. Emilio Arguello
Dr. Neil Neugeboren
Dr. Marcuschamer
CONTROL-CLICK (WINDOWS) OR COMMAND-CLICK (MAC) TO SELECT MORE THAN ONE.
REASON FOR REFERRAL
---
Comprehensive Periodontal Evaluation
Bone Graft / Regeneration
Implant Evaluation
Osseus Surger
Crown Lengthening
Gingivectomy
Soft Tissue Grafts
Frenectomy
Emergency Evaluation (problem focused)
Other
TOOTH #(S):
QUADS:
Has the patient had previous periodontal therapy?
None
Prophylaxis Only
Antimicrobial Therapy
Scaling and Root Planning
Surgery
Have you advised the patient of the possibility of extraction of any teeth?
Yes
No
IF YES WHICH TEETH?:
Does the patient require premedication?
Yes
No
ANTIBIOTIC USED:
Does the patient have pending treatment with your office?
Yes
No
NOTES:
RADIOGRAPHS:
Please take/send copy
Patient will bring copy
I will send / Please return
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:
Call me before seeing the patient
Alternate recare appointments
Send me report
Call patient to schedule
Call me after seeing the patient
Do all recall care after patient is treated
General Dentist signature:
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Resume Cover Letter:
*
Upload resume
Max. file size: 50 MB.
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