Referral information can be submitted electronically. Please fill out any applicable fields below. Thank you!
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Patient Referral Information
Reason for referral
Comprehensive periodontal exam and treatment
Gingival recession or mucogingival defect
Crown lengthening or pre-prosthetic surgery
Area of concern
Current radiographs available
We will email x-rays to email@example.com
The patient will bring xrays to your office
Please take a CMS or PA as needed
Current periodontal maintenance interval
every 3 months
every 4 months
every 6 months
every 12 months
Maintenance interval compliance
Date of last cleaning
History of scaling and root planing?
Do you have any restorative treatment planned for this patient?
Referring dentist name