REFERRING DENTISTS

THE PATIENT IS REFERRED TO

Dr. Maud Lassonde
Dr. Émilie Vachon
First available doctor

DATE

INFORMATION

REFERRED BY 

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)

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 upload a zip folder now
For instructions, click icon

COMMENTS