Referral Form

Date*

Patients name*

Contact number*

Date of birth

Reason's for referral
---ImplantsGingival recessionGraft for root coverageCrown lengtheningGuided tissue regenerationGingival contouring for cosmeticsRidge augmentationExtractionIV sedationOther

Tooth number(s)

Radiographs
---EmailingWith patientPlease takeNo x-ray

Periodontal evaluation
---EarlyModerateAdvanced

Periodontal treatment completed to date
---Plaque control instructionProphylaxis and gross scalingRoot planningPeriodontal maintenance therapy

Referring Dentist’s name*

Practice name*

Practice Contact number*

Email*

Have you advised patient of the possibility
of tooth extraction?
NoYes, tooth number

Is there any restorative dentistry that needs
to be competed?
NoYes, comment

Comments

A copy will be sent to the email entered above