Implant & Periodontal Clinic- Referral
Implants, Extractions, Oral Surgery and Periodontics
David A Baker DDS MSD
Diplomate of the American Board of Periodontology
Referring Dental Office
*
Dental Clinic
Dentist
Dental Clinic email (after submission you will receive a copy of this referral)
*
smiles@happydentist.com
Patient Name
*
First Name
Last Name
Phone Number
Best contact number for patient or caregiver.
Format: (000) 000-0000.
Birth Date
*
-
Month
-
Day
Year
Date
Patient email
patient@gmail.com
Dental Insurance
Direct pay
Care credit
Insurance
Recent SRP/ Deep cleaning ?
Dates/ quads
FOCUS: How can we help your patient?
Chief complaint and treatment plan summary.
Implant Tx Plan (check all)
Dental Implant(s)
Extraction / Implant
All-on"X" -Full arch
Regeneration
Provisionalization
Specific teeth #'s?
Periodontal Treatment Plan (check all)
Periodontal evaluation
Peri-implantitis
Esthetics- "Gummy smile"
Crown lengthening
Recession/ grafting evaluation
Corrective osseous surgery
Surgical Plan (check all)
Extraction(s)
Wisdom teeth
IV Sedation/ Oral sedation
Full-arch Ext, denture ready
Specific teeth #'s
Recent dentistry , medical issues
Any special dental or medical conditions to consider.
Available xrays
*
Yes, attached here
Yes, will upload soon
None, please take
Dropbox link (URL)
X-rays
Upload X-rays (browse)
Drag and drop files here
Choose a file
Attach all recent films, PAX, BW or PAN
Cancel
of
CBCT upload
CBCT upload (browse)
Drag and drop files here
Choose a file
Attach all recent films, PAX, BW or PAN
Cancel
of
Medical history upload
Medical history upload
Drag and drop files here
Choose a file
Upload medical hx and medications (if applicable)
Cancel
of
Patient Photos
Patient photos
Drag and drop files here
Choose a file
Upload medical hx and medications (if applicable)
Cancel
of
Referral date
*
-
Month
-
Day
Year
Date of X-rays
Caregiver name and phone #
If applicable: Contact for appointments
Print (optional, email copy will be sent)
Send to IPC, cc Dentist + patient
Should be Empty: