REFERRAL LETTER

Periodontal Referral Letter
FROM*
DATE*

MonthDayYear
PATIENT*
PHONE #(s)*
PATIENTS EMAIL ADDRESS*
REFERRED FOR*

Periodontal evaluation, diagnosis, and therapyDental implant evaluation and therapy
OUR MAIN CONCERNS*

Significant bleeding on probingDeep probing depthsBone loss/deformitiesDeep furcationsTissue recession/root exposureLack of protective attached gingivaRoot sensitivity
Crown lengthening neededOrthodonticsSmile line/gingival levelsEdentulous ridge augmentationExtract and preserve ridgeDental implants proposedTooth mobilityOther
Please Elaborate:*
PERTINENT HISTORY
Patient of Record

New
Since

MonthDayYear
Plaque control motivation/dexterity:*

ExcellentNeeds Improvement/Reinforcement
Recommended maintenance interval: *months.
Compliance has been:*

GoodFairInsufficient
Date of last maintenance visit*

MonthDayYear
Active periodontal therapy already performed:

Quadrant Scaling and Root Planing
Month/Year:

Location: Our Office Other
Perio Surgery
Month/Year:     ____________

Treated By:    ______________

Areas:    _________________
Anti-Microbial Therapy
RESTORATIVE AND/OR OTHER DENTAL NEEDS*

Patient is AwarePatient has not yet had restorative consultation
Crowns/Veneers
Fixed Bridges
Removable Prosthesis
Implants
Other:
IMPORTANT PATIENT INFORMATION
Readiness Level:*

High (understands problem(s) and wants treatment)UnknownMay Be Low
Patients Concerns/Stated Needs:*
CURRENT RADIOGRAPHS (FMX & VERTICAL BWX)*

Will be forwarded to your office before appointment.Unavailable/Out of date. Please have a new FMX taken and send a copy to our office.
Have Dr. Gasper call our office to discuss our patient before the examination appointment. She should speak directly to
Signatures:
Doctor:*

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Hygeinist

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Periodontal Referral Letter

PERTINENT HISTORY

IMPORTANT PATIENT INFORMATION

Signatures: