Patient Referral Form

First Name

Last Name

Birthdate

Todays Date

Address

City

State

Zip Code

Phone Number

Email Address

Is antibiotic prophylaxis required?

Yes No

Periodontal disease in the areas of:

Has periodontal scaling and root planing been completed?

Yes No

Gingival recession in the area/areas of:

Crown lengthening in the area/areas of:

Oral Pathology/Biopsy in the area of:

Other:

Referring DDS:

Referring RDH:

What restorative care, if any, is planned?

Additional Comments:

Please attach any radiographic images or pictures that will assist us in our diagnosis and treatment.