Implant & Periodontal Clinic- Patient Referral
When Excellence Matters
David Baker DDS MSD Victor Mak DDS MSD
Diplomates of the American Board of Periodontology
Referring Dental Office
*
Dental Clinic
Dentist
Dental Clinic email
*
smiles@happydentist.com
Patient Name
*
First Name
Last Name
Phone Number
Best contact number for patient or caregiver.
Birth Date
-
Month
-
Day
Year
Date
Patient email
patient@gmail.com
Dental Insurance
Private pay
Care credit
Insurance
Recent SRP ?
Dates/ quads
Implant Tx Plan
Dental Implant(s)
Extraction / Implant
Regeneration
Provisionalization
All-on"X" -Full arch
Tooth #'s, details...
Surgical Plan
Extraction(s)
Wisdom teeth
IV Sedation
Full-arch Ext, denture ready
Socket preservation/ grafting
Tooth #'s, details
Periodontal Treatment Plan
Periodontal evaluation
Deep Cleaning (SRP)
Esthetics- "Gummy smile"
Crown lengthening
Corrective osseous surgery
FOCUS: How can we help your patient?
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
Caregiver name
If applicable: Contact for appointments
Referral date
*
-
Month
-
Day
Year
Print (optional, email copy will be sent)
Send to IPC, cc Dentist + patient
Should be Empty: