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
1. How long has he/she been a patient?
2. When did you first recommend he/she see a periodontist?
3. Has a scaling been done at GPs office in the last 6 months?
4. you used code D4341 or D4342 within the last two years?
5. 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?
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:
1. Is the patient physically handicapped?  
 
Comments:
2. Is premedication needed?
  Condition 
3. In your office, does the patient prefer...
 
 
4. What is the patients apprehension level?

PLEASE SEND ADDITIONAL:

Dr. Date: *
Appointment Date: Time:

 
 
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