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Periodontist RP Form
Prosthodontist RP Form
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Home
First Visit
Treatment
Gums & Implants
Teeth & Dentures
Referring Practitioners
Periodontist RP Form
Prosthodontist RP Form
Our Practice
Community
Contact
Periodontist Referring Practitioners Form
Dr Tasha Mackie – Periodontist Specialist
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*
Date of Birth*
Address
Home Phone
Work Phone
Mobile Phone*
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
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