Demographic Information
Referring Information
Extraction Information
Demographic Information
Patient Information
Name
Date of Birth
Parent / Guardian
Phone
Email
Does the patient require antibiotics prior to dental treatment?
Yes
No
Please call patient
Yes
No
Treatment
Referring Information
Referring Doctor Information
Referred By
Phone
Email
Please enter a valid email address.
Procedures
Extraction (see tooth chart below)
Yes
No
Alveoloplasty
Yes
No
Biopsy
Yes
No
Incision and Drainage
Yes
No
Expose and Bond
Yes
No
Frenectomy
Yes
No
Flap Surgery
Yes
No
Gingival Recession
Yes
No
Sinus Elevation
Yes
No
Peri-implantitis
Yes
No
Scaling & Root Planing
Yes
No
Other:
Yes
No
Consultations
Implants
Yes
No
Immediate
Delayed
Pre-Prosthetic
Yes
No
Cosmetic (Gummy Smile)
Yes
No
Ridge Augmentation
Yes
No
Bone Grafting
Yes
No
All-On-4/Hybrid Dentures
Yes
No
Periodontal Consultation & Exam
Yes
No
Other:
Yes
No
Other Consultations
Implants
BioHorizon
Nobel BioCare
Straumann
Other
NeoDent
Surgical Template
Provided by Surgeon
Implant Coping, Analogs and Prosthetic Kit will be provided by the surgeon.
Extraction Information
Extractions
right
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
left
right
a
b
c
d
e
f
g
h
i
j
t
s
r
q
p
o
n
m
l
k
left
Please Verify Teeth for Extraction
Radiographs or Clinical Photos
TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SUBMIT THE FORM BELOW.
AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.
Radiographs / Clinical Photos
Being Mailed
Given to Patient
Please Take
No X-Ray
Attached with This Referral
If X-Rays are attached, what date were they taken:
Comments
Comments
