Dr. Referral Form

Referring Doctor Name
Introducing (Patient Name)
Complete Periodontal Exam
TMJ Evaluation
Limited Exam Area
Implant Consult Area
Ridge Augmentation Area
Fiberotomy Area
Frenectomy Area
Tori/Exostosis Removal Area
Crown Lengthening Tooth #
ENDO-PERIO Lesion Tooth #
Surgical Tooth Exposure with Appliance Tooth #
Gingival Graft Tooth #
Appointment Date
Time
Previous Periodontal Therapy

PAN/FMX
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X-rays/images/files
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Future restorative treatment planned
Remarks