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Referrals

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

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