Periodontic referral form Please fill out all fields below and submit the form, or alternatively download the PDF form.

Referring Dentist

• Name
• Practice
• Address
• Phone
• Fax
• Email

Patient Details

• Name
• DOB
• Address
• Home Phone
• Work Phone
• Mobile Phone
• Mobile Email
• Medical History
• Dental History / Oral Hygiene Methods
• Smoker / Non-smoker / History
• Account Number
• Date of Accident
• Requires antibiotic prophylaxis Requires sedation Non-ambulatory

Referral

• Periodontal disease (differential diagnosis)

• Gingivectomy	Tooth exposure	Pericision
  Soft tissue grafts	Frenectomy	Orthodontic anchorage implants
  Crown lengthening	Periodintal regeneration	Maintenance appointments

• Biospy (differential diagnosis)
• Dental Implants (sites)

• Sinus lift required	Bone grafting
  Implant overdentures	Peri-implantitis / peri-muscositis
  Please restore the implant (Dr Andrew Mackie - Prosthodontist)

• Other

Notes (teeth)

Radiographs enclosed

• PAs
• OPG
• Bite wings
• Please return radiographs