3690 S. Yosemite Street,
Denver, Colorado 80237

HomePeriodontal and Implant Referral Form

Periodontal and Implant 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!

Patient Name: *

Phone No: *

Doctor Name: *

Phone No: *

Office Email: *


Patient Referral To

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:

RADIOGRAPHS:

Please take/send copyPatient will bring copyI will send / Please return

UPLOAD X-RAY IMAGES:

You can upload up to 5 x-rays (limit 30mb each).
Must be a common image file type: .jpg, .gif, .png, .bmp, .tiff, .png, .pdf, word document.




ADDITIONAL COMMENTS:

PLEASE:

Call me before seeing the patientCall me after seeing the patientAlternate recare appointmentsDo all recareSend me reportGeneral Dentist signature:Call patient to schedule