Demographic Information
Referring Information
Extraction Information
Case Notes
Demographic Information
Patient Information
Name
Date of Birth
Parent / Guardian
Contact Telephone
Contact Email Address
Does the patient require antibiotics prior to dental treatment?
Yes
No
Please call patient
Yes
No
Treatment
Referring Information
Referring Doctor Information
Referred By
Telephone
Email Address
Please enter a valid email address.
Procedures
Extraction (see tooth chart below)
Yes
No
Alveoloplasty
Yes
No
Biopsy
Yes
No
Incision and Drainage
Yes
No
Lesion Evaluation
Yes
No
Exposure
Yes
No
Hard Tissue
Yes
No
Infection
Yes
No
Expose and Bond
Yes
No
Soft Tissue
Yes
No
Frenectomy
Yes
No
Apicoectomy
Yes
No
Other:
Yes
No
Consultations
TMJ
Yes
No
Implants
Yes
No
Immediate
Delayed
Orthognathic Evaluation
Yes
No
Pre-Prosthetic
Yes
No
Cleft Lip and Palate
Yes
No
Cosmetic
Yes
No
Ridge Augmentation
Yes
No
Oral / Facial Lesion
Yes
No
Bone Grafting
Yes
No
Other:
Yes
No
Other Consultations
Implants
Biomet 3i
Astra
BioHorizon
Implant Direct
Implant Innovations
Keystone / Lifecore
MiS
Nobel BioCare
Straumann
Zimmer
Other
Surgical Template
Provided by Restorative Dentist
Provided by Surgeon
Extraction Information
Extractions
right
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
left
right
a
b
c
d
e
f
g
h
i
j
t
s
r
q
p
o
n
m
l
k
left
Please Verify Teeth for Extraction
Radiographs or Clinical Photos
TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SELECT THE "Complete and Send" BUTTON BELOW. AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.
Radiographs / Clinical Photos
Being Mailed
Given to Patient
Please Take
No X-Ray
Attached with This Referral
If X-Rays are attached, what date were they taken:
Case Notes
Case Notes
