Pacific Northwest Specialists in Periodontics and Dental Implants - Online Referral Form
Please fill in the form below.
Please choose from one of the Doctors:
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Dr. Rapoport
Dr. Schuler
No Preference
Full Name
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Prefix
First Name
Last Name
Phone Number
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Area Code
Phone Number
Work Phone
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Area Code
Phone Number
Referring Doctor
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Email of referring office contact
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Referral Date
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Month
-
Day
Year
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Patient Scheduling Method
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Please call patient to schedule appointment
Patient will call to schedule appointment
Tooth Position: Using the Diagram below please identify the teethin question. If entering multiple numbers, use commas, as inthe format (14,2,5...)
Additional Questions (check all that apply)
Comprehensive periodontal examination
Limited examination
Emergency examination
Clinical crown lengthening
Soft tissue grafting
Frenectomy
Implant examination
Ridge augmentation
Sinus augmentation
Uncovering impacted teeth
Fiberotomy
Extraction
Remarks
Recent full mouth radiographs available
Yes
No
Date Images Taken
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Month
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Day
Year
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Click here to attach radiographs, photographs and other images:
Send Patient Info
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