Demographic Information
Introducing
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Phone
*
Format: (000) 000-0000.
Referring Doctor
*
Phone
*
Format: (000) 000-0000.
Email:
*
Please Evaluate For
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Periodontal Examination and Consultation
Soft Tissue Grafting
Crown Lengthening
Pre or Post-Orthodontic Treatment
Extraction/Ridge Preservation
Implants
Implant Site Preparation
Other
Reason for Referral
*
Please Select
Periodontal Examination and Consultation
Soft Tissue Grafting
Crown Lengthening
Pre or Post-Orthodontic Treatment
Extraction/Ridge Preservation
Implants
Implant Site Preparation
Other
Other
Tooth #(S):
Quads:
Has the patient had previous periodontal therapy?
None
Prophylaxis Only
Antimicrobial Therapy
Scaling And Root Planning
Surgery
Have you advised the patient of the possibility of extraction of any teeth?
Yes
No
If Yes Which Teeth?
Does the patient require premedication?
Yes
No
Antibiotic Used:
Does the patient have pending treatment with your office?
Yes
No
Notes
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Additonal Follow Up questions:
*
Alternate Recare Appointments
Call Me Before Seeing The Patient
Call Me After Seeing The Patient
Call Patient To Schedule
Do All Recall Care After Patient Is Treated
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