Referral Form for Ed Liu DDS Implant & Sedation Dentistry
Implant service
Tooth or teeth number
*
Extraction required?
*
Yes
No
CBCT needed?
*
Yes
No
Do you wish to have pre design approval before we proceed? Via ZOOM meeting
Prosthetics Service
(send your IOS scan and 3d/ 2d pictures if you have them)
Do you wish to review pre-design before we proceed? Via ZOOM meeting
3D printed porcelain resin?
Use FDA approved porcelain resin.
Final prosthetics services?
What is your preferred material?
*
Ti Bar
Zr
Porcelain Resin
Special prosthetic screws?
IV sedation sedation for general dental service
Reason for referral
What is needed to be done
TM Jand Bioesthetics services
(Please send patient cbct if you have)
TMJ discomfort?
*
Yes
No
MAGO appliance?
(Mandibular repositioning applianance)
Referring doctor
Notes
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: