PATIENT INFORMATION:
Does the patient require antibiotics prior to dental treatment?
Yes No • Don’t Call Patient Please call patient
REFERRING DOCTOR’S INFORMATION:
PROCEDURES:
Extraction (see below)
Alveoloplasty
Biopsy
Incision & Drainage
Lesion Evaluation
Infection
Expose & Bond
Frenectomy
Apicoectomy
Other
Area's of Concern
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
A
B
C
D
E
F
G
H
I
J
T
S
R
Q
P
O
N
M
L
K
Please Verify Teeth for Extraction
Please extract mandibular right and left 1st premolars (#21 and #28)
CONSULTATIONS:
TMJ
Implants:
Immediate
Delayed
Orthognathic Evaluation
Pre-Prosthetic
Bone Grafting
Others Consultations
Implant:
Surgical Template:
RADIOGRAPHS OR CLINICAL PHOTOS:
TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SUBMIT THE FORM ABOVE OR BELOW.
CASE NOTES:
RADIOGRAPHS OR CLINICAL PHOTOS ATTACHED FILE:
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