Dr. Wade Pilling - Referral Form

  • Wade A. Pilling DMD, DABOI, FAAID

    Board Certified Implant Specialist

  • Demographic Information

  • Patient Information

  • Extraction Information

  • Procedures to be considered:

  • Extraction
  • Implant
  • Ridge Augmentation
  • Sinus Augmentation
  • Full Arch (All-on-4)
  • Locator supported Denture
  • Extraction Only
  • Defer treatment plan to Dr. Pilling

  • Implant System Preference

  • Straumann
  • Nobel Biocare
  • Astra
  • Biohorizons
  • No preference
  • Radiographs / Clinical Photos
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  • If uploading an X-Ray, when was the X-Ray last taken?
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  • Impression Coping Preference

  • Preference

  • All new patient consultations, including radiographs & CBCT-scans taken, are complimentary.

    New patients save time by filling out new patient forms & medical history online prior to your appointment. In addition to the referral slip, please remember to bring the following to your appointment:

    • Insurance cards
    • Copy of most recent blood work
    • All medications/supplements being taken.

  • Download pdf version of the form.

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