Table of Contents
PERIODONTAL REFERRAL FORM

For your convenience, we have provided the following online referral form...

Date:
Time:
First Name:
Last Name:
Referred By:
Telephone:

REASON FOR REFERRAL

Complete Periodontal Evaluation 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

How would you like to manage the supportive periodontal treatment if necessary?
Alternate your office & periodontal office every three months.
Periodontal office only.
Your office only.
No difference.

Have you advised the patient of the possibility of extraction of any teeth? If yes, which tooth numbers?

Tooth #s:

(Please include digital photographs and/or radiographs by e-mail attachment.)

Is there any restorative dentistry that needs to be completed?

Other comments:

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