Periodontal Referral

Please Send Radiographs:

Panograph Date obtained:
Peri-apical Date obtained:
Bitewing Date obtained:
CBCT Date obtained:

Referral Details

General Assessment
Specific Area
Implant Surgery
Crown Lengthening
Soft Tissue Grafting
4 1/2 month Alternate Cleaning
Pathology
Iv Sedation

Medical Concerns / Treatment Plan / Comments

Attachment

Maximum 5 files will be uploaded.