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 prophylaxisRequires sedationNon-ambulatory

    Referral

    Periodontal disease (differential diagnosis)
    GingivectomyTooth exposurePericisionSoft tissue graftsFrenectomyOrthodontic anchorage implantsCrown lengtheningPeriodintal regenerationMaintenance appointments
    Biospy (differential diagnosis)
    Dental Implants (sites)
    Sinus lift requiredBone graftingImplant overdenturesPeri-implantitis / peri-muscositisPlease restore the implant (Dr Andrew Mackie - Prosthodontist)
    Other

    Notes (teeth)

    Radiographs enclosed

    PAsOPGBite wingsPlease return radiographs
    Please prove you are human by selecting the Key.