mdoperio.com - Referral Form

Specializing in Periodontics
Marc D. Orjansen D.D.S., M.S.

Specializing in Periodontics

(320) 240-9028 Office • (320) 240-9048 Fax • www.mdoperio.com

1900 Kruchten Ct. S., Suite 101
Sartell, MN 56377-4731
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Reason for Referral:
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ImplantsTissue GraftBiopsyFrenulectomyPeriodontal DiseasePerio-implantitis
Periodontal Disease

LocalizedFull Mouth
Perio-implantitis: Date

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Perio-implantitis: Type & Size
We request x-rays for all patients.

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I Am Sending:

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Panoramic Radiograph
Full Mouth Radiographs
Periapical Radiograph
Bite Wing Radiograph

Treatment Your Office Has Performed:

Initial Examination OnlyScaling and Root PlanningOther
Scaling and Root Planning

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