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

Referring Dentist

Patient Details

  • Requires antibiotic prophylaxis Requires sedation Non-ambulatory

Referral

  • Gingivectomy Tooth exposure Pericision
    Soft tissue grafts Frenectomy Orthodontic anchorage implants
    Crown lengthening Periodintal regeneration Maintenance appointments
  • Sinus lift required Bone grafting
    Implant overdentures Peri-implantitis / peri-muscositis
    Please restore the implant
    (Dr Andrew Mackie - Prosthodontist)

Notes (teeth)

Radiographs enclosed

  • PAs
  • OPG
  • Bite wings
  • Please return radiographs
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