Referral Form

Patient Information

Name

Date of Birth

Parent/Guardian Name

Email

Phone *

Does the patient require antibiotics prior to dental treatment?

Yes

No

Treatment

Referring Doctor Information

Referred By

Referrer's Email

Referrer's Phone *

Referred for the Following

Complete Periodontal Evaluation

Yes

No

Dental Implants

Yes

No

Extraction

Yes

No

Bone Grafting

Yes

No

Gum Grafting

Yes

No

Crown Lengthening

Yes

No

Cosmetic Gum Contouring

Yes

No

Laser Treatment for Gum Disease

Yes

No

Peri-Implantitis Treatment

Yes

No

Frenectomy

Yes

No

Other:

Please specify the area(s) desired to be evaluated and treated:

Radiographs or Clinical Photos

TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SELECT THE "Complete and Send" BUTTON BELOW.

AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.

File(s) Upload

Maximum file size: 516MB

If uploading files, please specify date the attachments are from:

Consultations

Implants

Straumann

Thommen

Surgical Template

Provided by Periodontist

Provided by Restorative Dentist

Periodontal Treatment Completed in Your Office

Prophylaxis

Yes

No

Oral Hygiene Instruction

Yes

No

Scaling and Root Planning

Yes

No

Periodontal Maintenance

Yes

No

Other

Is There Any Restorative Dentistry that Needs to be Completed?

Restorative Comments

Case Notes

Please include any additional information that may assist us in helping your patient. Thank you!

From Referring Doctors

Referral Form

Referral Form

Patient Information

Referring Doctor Information

Referred for the Following

Radiographs or Clinical Photos

Consultations

Periodontal Treatment Completed in Your Office

Is There Any Restorative Dentistry that Needs to be Completed?

Case Notes