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Referral
Dentist Referral Form
Please complete all required fields below.
DATE
*
INFORMATION
Patient's name
*
Phone number
*
Email
REFERRED BY
Name of the dentist/specialist
*
REASON FOR APPOINTMENT
*
Full periodontal assessment
Emergency treatment
Bone surgery
Guided tissue regeneration
Gingival graft
Extraction and alveolar bone graft
Guided bone regeneration
Sinus lift and bone graft
Dental implant
Peri-implantitis
Surgical crown lengthening
Surgical exposure of an impacted tooth
Frenectomy
Biopsy
Other (check box and specify below)
I confirm that the information listed above is correct.
*
TOOTH NUMBER/REGION
APPOINTMENT
*
Please contact the patient for an appointment
The patient will call for an appointment
X-RAYS
*
Given to patient
No X-rays available
I will send you the X-rays by email to info@groupedentairepardo.ca
COMMENTS
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