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Referrals Date: Time: First Name: Last Name: Referred By: Telephone: COMPLETE PERIODONTAL EVALUATION REASON FOR REFERRAL RADIOGRAPHS Implants Being Mailed Given to Patient Please Take No X-Ray Gingival Recession IMPLANTS Graft For Root Coverage Dentsply Implant Innovations ITI Lifecore TMI Branemark Other Restore Crown Lengthening SURGICAL TEMPLATE Guided Tissue Regeneration Provided by Restorative Dentist Provided by Periodontist Gingival Contouring For Cosmetics Ridge Augmentation Other PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE Plaque Control Instruction Prophylaxis and Gross Scaling Root Planning Periodontal Maintenance Therapy Have you advised the patient of the possibility of extraction of any teeth? If yes, which tooth numbers? Tooth #s: Please include digital radiograph by pressing the browse button and locating the image on your hard drive: Is there any restorative dentistry that needs to be completed? COMMENTS Welcome | Meet the Doctors | Periodontal Disease | Medical Consequences | Medical Consequences | Procedures | Implants | Contact | FAQ | Referrals @2008 D & D Periodontal Associates | SEO, Search Engine Optimization by GetMeOnTop
Date:
Time:
First Name:
Last Name:
Referred By:
Telephone:
COMPLETE PERIODONTAL EVALUATION
REASON FOR REFERRAL
RADIOGRAPHS
Implants
Gingival Recession
IMPLANTS
Graft For Root Coverage
Crown Lengthening
SURGICAL TEMPLATE
Guided Tissue Regeneration
Gingival Contouring For Cosmetics
Ridge Augmentation
Other
PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE
Plaque Control Instruction
Prophylaxis and Gross Scaling
Root Planning
Periodontal Maintenance Therapy
Have you advised the patient of the possibility of extraction of any teeth? If yes, which tooth numbers?
Tooth #s:
Please include digital radiograph by pressing the browse button and locating the image on your hard drive:
Is there any restorative dentistry that needs to be completed?
COMMENTS
Welcome | Meet the Doctors | Periodontal Disease | Medical Consequences | Medical Consequences | Procedures | Implants | Contact | FAQ | Referrals
@2008 D & D Periodontal Associates | SEO, Search Engine Optimization by GetMeOnTop