2020 SW 27th Avenue
Miami, FL 33145
Map | 305.447.1447

Periodontics - Implant Dentistry

2020 SW 27th Avenue
Miami, Florida 33145

Phone/Fax:

305 447-1447
305 447-4559 fax

PATIENT NAME: *

ADDRESS:

APPOINTMENT (Please check one):

	Please call patient for appointment. Patient phone number:

	Patient will call your office for appointment.

I AM REFERRING THIS PATIENT FOR (Please check all that apply):

Periodontal Evaluation

How long has he/she been a patient?

When did you first recommend he/she see a periodontist?

Has a scaling been done at GPs office in the last 6 months?

Yes

you used code D4341 or D4342 within the last two years?

Yes

What recall cycle has the patient been on?

Implants Tooth #(s)

Soft Tissue Graft - Tooth #(s)

Crown Lengthening Procedure - Tooth #

Other

X-RAYS (Please check one):

A complete series:

Maxillary

Mandibular

ANTICIPATED TREATMENT PLAN:

What would your ideal anticipated treatment plan be?

Crowns (Tooth #s):

Bridges (locations):

Remov. prosth. (location)

Implants:

Has this been discussed with the patient?

Yes

Comments:

Upon patients completion of periodontal treatment, please call us to schedule an appointment for him/her with our office.

TO HELP US BETTER PREPARE: