305-447-1447

Patient Referral

Dr. John Paul Gallardo

Our office is located at:

2020 SW 27th Avenue
Miami, Florida 33145

Phone/Fax:

305 447-1447
305 447-4559 fax

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APPOINTMENT (Please check one):

I AM REFERRING THIS PATIENT FOR (Please check all that apply):
3. Has a prophy been done at GPs office in the last 6 months?
4. You used code D4341 or D4342 within the last two years?

Wisdom Teeth Evaluation:

X-RAYS (Please check one):
A complete series:
imageMaxillary
Mandibular

ANTICIPATED TREATMENT PLAN: What would your ideal anticipated treatment plan be?
Has this been discussed with the patient?

TO HELP US BETTER PREPARE:
1. Is the patient physically handicapped?
2. Is premedication needed?
4. What is the patients apprehension level?

PLEASE SEND ADDITIONAL:
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