Patient Name:
Home Phone:          Work Phone:
Referring Dentist:
Referring Dentist's Email Address:
(Entering your Email address will enable you to receive a copy of this referral.)

I. Treatment Desired:
  Complete Perio Eval
  Emergency Care
  Particular Problem Area (See Below)
R 1 2 3 4 5 6 7 8 U 9 10 11 12 13 14 15 16L
32 31 30 29 28 27 26 25 L 24 23 22 21 20 19 18 17

  Implant Placement (See Below)
R 1 2 3 4 5 6 7 8 U 9 10 11 12 13 14 15 16L
32 31 30 29 28 27 26 25 L 24 23 22 21 20 19 18 17

II. Your Periodontal Findings:

III. Patient Information:
Has Periodontal problem been explained ?YesNo
Has Patient been appointed with our office ?YesNo
Have Root Planings been done ?Yes No    Date:

IV. Medication History:
Does this patient require pre-medication before dental treatment ?YesNo
If Yes, will you pre-medicate the patient for their first visit to our office ?YesNo

V. Full Mouth Radiographs
  Sent with Patient
  Mailed
  To be taken

VI. Your opinion as to therapy:

          Dr.



REFERRAL FORM