New Patient Referral Form

From:

Date

Fax Number

Phone Number

Date of Birth

Patient Contact Method (Select One)

Please perform a comprehensive exam

Please perform a limited exam for ( enter name below)

Patient has completed initial therapy

and requires a surgical evaluation for:

Please list what needs to be evaluated. (Crown Lengthening,

Guided tissue regeneration,

Ridge augmentation, Exposure of impacted tooth,

Soft Tissue graft, Guided bone regeneration,

Sinus elevation UR/UL, Other (Please list all that apply below)

Please list what needs to be evaluated. (Crown Lengthening,

Guided tissue regeneration,

Ridge augmentation, Exposure of impacted tooth,

Soft Tissue graft, Guided bone regeneration,

Sinus elevation UR/UL, Other (Please list all that apply below)

Please evaluate for dental implants

If YES was selected above,

please give details of the area and the proposed restorative plan

If YES was selected above,

please give details of the area and the proposed restorative plan

Patient's Primary Concern(s)

Misc. Comments

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