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 NUMBEREMAIL* DOCTOR OF CHOICEDoctor of ChoiceDr. John P. GallardoAPPOINTMENT (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?YesNo4. You used code D4341 or D4342 within the last two years?YesNo5. 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 enclosedis availablehas been mailedif needed, please take filmspatient will bring 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 MaxillaryMandibular 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?YesNoComments: 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?YesNoComments:2. Is premedication needed?YesNoCondition:4. What is the patients apprehension level?RelaxedNormal AmountVery AnxiousOtherPLEASE 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.EmailThis field is for validation purposes and should be left unchanged.
