Periodontal and Surgical Referral Form

SURGICAL &PERIODONTAL REFERRAL FORM
Date

MonthDayYear
Date
PATIENT INFORMATION
Name*

First NameLast Name
DOB

MonthDayYear
Date
Contact telephone
Please enter a valid phone number.
Contact E-mail
example@example.com
Patient Pictures

Cancelof
Does the patient require antibiotics prior to dental treatment?

YesNo
REFERRING DOCTOR'S INFORMATION:
Referred by
Telephone
Please enter a valid phone number.
E-mail address
example@example.com
REASON FOR REFERRAL (please check):

Complete Periodontal Evaluation(Early)Complete Periodontal Evaluation(Moderate)Complete Periodontal Evaluation(Advanced)Crown LengtheningRidge AugmentationGrafting for root coverageComplete Oral Surgery EvaluationExtractionsWisdom TeethImplant ConsultationSurgical template/guideGuided Tissue Regeneration (GTR)Gingival Contouring for Cosmetic Restorations
PLEASE INDICATE TOOTH NUMBER(s):

1234567891011121314151617181920212223242526272829303132
RADIOGRAPHS:

Please takeGiven to patientBeing mailedNo x-rays
PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE:

Plaque control instructionProphylaxis and Gross ScalingPeriodontal MaintenanceTherapy (PMT)No periodontal treatment renderedRoot planing & scaling (SRP)
Have you advised the patient of the possibility of extractions? If so, which tooth number(s)
IS THERE ANY RESTORATIVE DENTISTRY THAT NEEDS TO BE COMPLETED?

YesNo
IF SO, WHAT IS PLANNED?
COMMENTS
Eldridge Dental 6370 N Eldridge Pkwy, Suite B, Houston, TX 77041 P: (713)983-0099 F: (713)983-0071

www.eldridge-dent.com

Please email all x-rays to: eldridgedent@gmail.com
Should be Empty:

SURGICAL &PERIODONTAL REFERRAL FORM

PATIENT INFORMATION