48 Hours notice is necessary if unable to honor appointment
Please check if antibiotic PREMEDICATION is required for dental appointments.
Referral for:
Complete periodontal evaluation
Limited periodontal exam, area(s):
Evaluation for LANAP/LAPIP
Esthetic gingival recontouring prior to comprehensive restorative treatment
Gingival asymmetry
Gummy smile
Ridge augmentation to enhance esthetics in pontic area
Crown lengthening, area(s)
Frenectomy, area(s)
Gingival recession/mucogingival defect, area(s)
Dental implant evaluation, area(s)
Extraction and Ridge Preservation
GBR/Bone Grafting
Sinus Lift
Orthodontic Co-Therapy
Tooth Exposure, area(s)
TAD Placement, area(s)
Piezocision, area(s)
Alternating periodontal maintenance every
Other:
Regular
Sporadic
Little/None
Prophylaxis / OHI (mo. /vr. )
Patient of record since (mo. /yr. )
Root planning / initial therapy (mo. /yr. )
Previous periodontal therapy (mo. /yr. )
New Patient
To be emailed
Patient will bring
To be mailed
Take at time of periodontal evaluation and send me a duplicate set
Call me before evaluation of this patient
Call me after evaluation of this patient
