Expressions Doctor's Referral Form

Patient's Information
Patient's Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Responsible Party

SelfParent/Guardian
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Are Radiographs Available?*

YesNo
Please Upload

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Are Digital Photos Available?*

YesNo
Please Upload

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I recommend examining this patient for the following

Complete assessment, dental hygiene diagnosis, planning, implementation and evaluationOral Cancer ScreeningMicroscopic bacterial analysisRegular dental hygiene cleanings, periodontal therapy and maintenanceDesensitizationSports GuardPit and Fissure SealantsCounselling (oral hygiene instruction, nutritional counselling, tobacco cessation)Stain RemovalTemporary fillingsLaser for bacterial therapy, treatment of cold sores and dental senstivityOther
Concerns and Comments
Should be Empty:

Patient's Information