Referring Doctors Referring Doctors Patient Information Name Name First First Last Last Parent/Guardian Parent/Guardian First First Last Last Contact Telephone Contact Email Address Does the patient require antibiotics prior to dental treatment? Yes No Please call patient Yes No Treatment Referring Doctor Information Name Name First First Last Last Phone Email Procedures Extractions Yes No Alveoplasty Yes No Biopsy Yes No Incision & Drainage Yes No Lesion Evaluation Yes No Exposure Yes No Hard Tissue Yes No Infection Yes No Expose & Bond Yes No Soft Tissue Yes No Frenectomy Yes No Apicoectomy Yes No Other Consultations TMJ Yes No Implants Yes No Orthognathic Evaluation Yes No Pre-Prosthetic Yes No Cleft Lip & Palate Yes No Date Of Birth Cosmetic Yes No Ridge Augmentation Yes No Oral / Facial Lesion Yes No Bone Grafting Yes No Paragraph Implants Implants Please SelectDentsplyImplant DirectImplant InnovationsITILifecoreTMIBranemarkOther Surgical Template Please SelectProvided by PeriodontistProvided by Restorative Dentist Radiographs or Clinical Photos TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SELECT THE “Complete and Send” BUTTON BELOW. AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM. Radiographs / Clinical Photos Being Mailed Given to Patient Please Take No X-Ray Attached with This Referral If X-Rays are attached… Case Notes Comments Complete and Send If you are human, leave this field blank. Δ
