REFERRING DENTISTS

DATE*

INFORMATION

REFERRED BY

REASON FOR APPOINTMENT*

Full periodontal assessmentEmergency treatmentBone surgeryGuided tissue regenerationGingival graftExtraction and alveolar bone graftGuided bone regenerationSinus lift and bone graftDental implantPeri-implantitisSurgical crown lengtheningSurgical exposure of an impacted toothFrenectomyBiopsyOther (check box and specify below)

TOOTH NUMBER/REGION

APPOINTMENT*

Please contact the patient for an appointmentThe patient will call for an appointment

X-RAYS*

Given to patientNo X-rays availableI will send you the X-rays by email to info@paroimplantorivesud.com

COMMENTS