A. Garrett Gouldin, DDS, MS, PC
Francisco T. Carlos, DMD, MSD, PC
Vishal Gohel, DMD, MS, PLLC
NORTHERN VIRGINIA PERIODONTICS
FALLS CHURCH (703) 534-1766 ALEXANDRIA (703) 683-0117
DATE:
-
Month
-
Day
Year
Date
PATIENT NAME:
PHONE NUMBER:
Format: (000) 000-0000.
REFERRED TO:
Dr. Gouldin
Dr. Carlos
Dr. Gohel
First available
REASON FOR REFERRAL:
Dental implant evaluation:
Localized #(s)
Full arch:
Maxillary
Mandibular
•System preference:
Zim Vie
BioHorizons
Straumann
Existing implant evaluation: #(s) (Peri-implantitis, Peri-imlpant mucositis)
Periodontal evaluation:
Comprehensive
Localized #(s)
Crown lengthening #(s)
Extraction #(s)
Soft tissue evaluation:
Recession #(s)
Lack of keratinized/attached gingiva #(s)
Other
Esthetic evaluation:
Gummy smile
Gingival asymmetry #(s)
Other:
Orthodontic evaluation:
T.A.D. placement sites
P.A.O.O./S.F.O.T. (Wilkodontics)
Expose crown/bond bracket #(s)
M.A.R.P.E.
Oral pathology evaluation:
RADIOGRAPHS:
RADIOGRAPHS:
We are sending radiographs
Patient is bringing radiographs
No recent radiographs available
APPOINTMENT STATUS:
APPOINTMENT STATUS:
Made by our office
Your office to call patient
Patient will call
COMMUNICATION:
Please call me regarding this patient
Before your evaluation.
After your evaluation.
No need to call - written correspondence will suffice.
SPECIAL INSTRUCTIONS / DETAILS:
Please send additional referral forms.
REFERRED BY DR.
Dental Implants • Minimally Invasive Periodontics • Laser Periodontal Therapy
103 West Broad Street, Suite 601 • Falls Church, VA 22046 • Office (703) 534-1766 • Fax (703) 534-1979
1900 Duke Street, Suite 110 • Alexandria, VA 22314 • Office (703) 683-0117• Fax (703) 683-5577
www.NorthernVaPerio.com
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