Periodontal Referral Form Template

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PERIODONTAL REFERRAL FORM
Patient Name: _____________________________________________ Phone No: ______________________
Referring Doctor Name: _____________________________________ Phone No: _____________________
Address: _________________________________________________________________________________
Reason for Referral
Periodontal Evaluation Only
o
Bone Graft
o
Implant
o
Osseous Surgery
o
Crown Lengthening
o
Gingivectomy
o
Tissue Grafts
o
Frenectomy
o
Emergency Evaluation (problem focused)
o
Other
o
Tooth #(s) __________________
Quads: ______________________
Has the patient had previous periodontal therapy?
None
o
Prophylaxis Only
o
Antimicrobial Therapy
o
Scaling and Root Planning
o
Surgery
o
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: ____________________________________________
Radiographs:
Please take/send copy
Patient will bring copy
I will send / Please return
Your Restorative Plans
_________________________________________________________________________________________
_________________________________________________________________________________________
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please
Call me before seeing the patient
Call me after seeing the patient
Alternate recare appointments
Do all recare
General Dentist signature: ____________________
Date: _________________
PERIODONTAL REFERRAL FORM
Patient Name: _____________________________________________ Phone No: ______________________
Referring Doctor Name: _____________________________________ Phone No: _____________________
Address: _________________________________________________________________________________
Reason for Referral
Periodontal Evaluation Only
o
Bone Graft
o
Implant
o
Osseous Surgery
o
Crown Lengthening
o
Gingivectomy
o
Tissue Grafts
o
Frenectomy
o
Emergency Evaluation (problem focused)
o
Other
o
Tooth #(s) __________________
Quads: ______________________
Has the patient had previous periodontal therapy?
None
o
Prophylaxis Only
o
Antimicrobial Therapy
o
Scaling and Root Planning
o
Surgery
o
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: ____________________________________________
Radiographs:
Please take/send copy
Patient will bring copy
I will send / Please return
Your Restorative Plans
_________________________________________________________________________________________
_________________________________________________________________________________________
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please
Call me before seeing the patient
Call me after seeing the patient
Alternate recare appointments
Do all recare
General Dentist signature: ____________________
Date: _________________

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