PATIENT INFORMATION
Today’s Date:
*
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Month
-
Day
Year
First Name
*
Last Name
*
Date of Birth
*
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Month
-
Day
Year
Sex
M
F
Name of Insurance Company
Insurance ID #
Subscriber Name:
Date of Birth
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Month
-
Day
Year
Insurance Amount Pending From Your Office
Contact Telephone
*
Format: (000) 000-0000.
Contact Email Address
*
Preferred Contact Method
Patient will call for appointment
Please call patient
REFERRING DOCTOR’S INFORMATION
Referred By
Office Telephone
*
Format: (000) 000-0000.
Email Address
*
RADIOGRAPHS
Emailed to staff@rootsandgums.com
Please take radiographs as necessary
Copy of CBCT given to patient
PERIODONTAL REFERRAL
*
Dental Implants (Single / Multiple / All-On-X)
Periodontal Disease
Gum Graft / Recession
Extract
Ridge Augmentation / Sinus Lift
Crown Lengthening (Functional / Cosmetic)
Infected or Failing Implant
Frenectomy
Biopsy
Other
ENDODONTIC REFERRAL
Tooth Presents With:
Pain: Cold / Hot / Biting
Swelling
History of Trauma
Crack or Fracture
Root Resorption
Reason For Referral:
Consultation only
Root Canal Treatment
Apicoectomy
Retreatment
Restorative Preference:
Temporary Filling
Leave Post Space
Build Up
Post and Build Up
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Case Notes:
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