Referring Doctor Appointment Time Patient Appointment Date Comments? Radiographs: Please Take New Radiographs Please Take A CBCT Scan Accompanying Patient Mailed To Your Office Emailed To Your Office Sedation Restorative Need / Options Periodontal Concerns Periodontal Disease Recession Crown Lengthening Exposure Peri-Implantitus Extraction Laser Treatment Hygiene / Periodontal Maintenance Periodontist Alternating Referring Dentist Scaling and Root Planing Date Completed Periodontist Cosmetic Concerns Esthetic Crown Lengthening Gingival Augmentation Frenectomy Dental Implants Extraction Bone Graft Sinus Lift Implant Implant Brand
