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Online Referral
Date of Referral
Dr. Office Phone Number*
Referring Doctor*
Referring Doctor Email*
General Practitioner
Referring Hygienist
Introducing
Mr
Ms
Mrs
Dr
Last Name
First Name
Patient Email*
Home Phone Number
Work Phone Number
Cell Phone Number
Please Evaluate
Periodontal Condition
Osseointegrated Implant Therapy
Crown Lengthening
Cosmetic Gingival Recontouring
Biopsy
Tissue Grafting
Recession
Periapical Abscess
Frenulectomy and Fiberotomy
Periodontal Maintenance Care
Impacted Tooth Exposure
Endodontic/Periapical Surgery
Laser Periodontal Therapy
Special Problem Areas
Other:
PLEASE CONTACT PATIENT TO SCHEDULE AN EXAMINATION APPOINTMENT.
Appointment Date
Appointment Time
AM
PM
*If unable to honor appointment please give courtesy of 48 hours notice: (770) 740-0442
If you have dental insurance, be sure to bring your insurance card with you.
PLEASE PROVIDE THE FOLLOWING PERIODONTAL REFERRAL INFORMATION
Radiographs taken in the last 3 years
PAN
FMX
PA
BW
Being sent with
Patient
Mailed to us
Emailed to us
Last Prophylaxis
Last Scale/Root Planing
Major Restorative Treatment Planned/Completed
Any Other Information