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Referral Form
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Patient Name
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First
Email
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Phone
(Required)
Name of Referring Doctor
(Required)
Tooth# / Sites to be evaluated: (Please mark the following)
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Date
MM slash DD slash YYYY
Document included (Please mark the following)
FMX / BW
Panorex
CBCT
Introral(IO) Scan / Photos
Tx. Notes
Document included (Please mark the following)
To patient
By mail
By email
Reasons for Referral:
Complete Periodontal Evaluation
Crown Lengthening: Functional / Esthectic
Gum recession / Lack of attached gingiva
Extractions and Grafting
Implant
Perio - Ortho Consideration:
Anesthesia:
Laser LANAP Periodontal Therapy
Bone Augmentation
Sinus Lift
Tori / Extosis Removal
Guided Tissue Regeneration (GTR) around teeth
Apicoectomy
others
Anesthesia: (Options)
Frenectomy
Canine Exposure
Corticotomy / PAOO
Perio - Ortho Consideration: (Options)
Frenectomy
Canine Exposure
Corticotomy / PAOO
Implants (options)
Single Unit
Multiple Unit
Full mouth / All on X
Additional Comments
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