Innovative Periodontics and Dental Implants
Demographic Information
Patient Information
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent / Guardian Name
First Name
Last Name
Contact Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Contact E-Mail Address
example@example.com
Does the patient require antibiotics prior to dental treatment?
Yes
No
Please call patient
Patient will call for appointment
Treatment
Referring Information
Referring Doctor's Information
Referred By
First Name
Last Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
E-Mail Address
example@example.com
Referred for the Following
Complete Periodontal Evaluation
Yes
No
Early
Moderate
Advanced
Implants
Yes
No
Immediate
Delayed
Gingival Recession
Yes
No
Graft for Root Coverage
Yes
No
Crown Lengthening
Yes
No
Teeth #
Guided Tissue Regeneration
Yes
No
Teeth #
Gingival Contouring for Cosmetics
Yes
No
Teeth #
Ridge Augmentation
Yes
No
Extraction
Yes
No
Other
Yes
No
Other Reason
Possible Extractions
Possible Extractions
Have you advised the patient of the possibility of extraction?
Mark on Image
Radiograph or Clinical Photos
ATTACH X-RAY(S) TO THIS REFERRAL FORM
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of
Radiograph / Clinical Photo
Being Mailed
Given To Patient
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No X-Ray
Attached with this Referral
If X-Rays are attached, what date were they taken
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Consultations
Implants
Dentsply
Implant Direct
Implant Innovations
ITI
Lifecore
TMI
Branemark
Other
Surgical Template
Provided by Periodontist
Provided by Restorative Dentist
Periodontal Treatment Completed in Your Office
Plaque Control Instruction
Yes
No
Prophylaxis and Gross Scaling
Yes
No
Root Planning
Yes
No
Periodontal Maintenance Therapy
Yes
No
Is There Any Restorative Dentistry that Needs to be Completed?
Restorative Comments
Case Notes
Case Notes
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