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 PATIENT NAME:* PATIENT PHONE NUMBER EMAIL* DOCTOR OF CHOICEDoctor of Choice Dr. John P. Gallardo APPOINTMENT (Please check one): Please call patient for appointment. 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 prophy been done at GPs office in the last 6 months? Yes No 4. You used code D4341 or D4342 within the last two years? Yes No 5. What recall cycle has the patient been on? Implants Tooth #(s) Soft Tissue Graft - Tooth #(s) Crown Lengthening Procedure - Tooth # Other Wisdom Teeth Evaluation: 1. How long has he/she been a patient? 2. When did you first recommend he/she see an oral surgeon? X-RAYS (Please check one): A complete series: is enclosed is available has been mailed if needed, please take films patient will bring 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Maxillary Mandibular 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 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 No 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? Yes No Comments: 2. Is premedication needed? Yes No Condition: 4. What is the patients apprehension level? Relaxed Normal Amount Very Anxious Other PLEASE SEND ADDITIONAL: X-ray envelopes Implant Referral Forms Patient Periodontal Brochures Treatment Planning Sheets Dr. By submitting this form I agree to the Terms of Use. Email This field is for validation purposes and should be left unchanged. Δ
