Pylant Periodontics - Patient Referral

Patient Information
Patient Name

First NameLast Name
Birth Date

MonthDayYear
Patient Phone Number

Area CodePhone Number
Today's Date

MonthDayYear
Date
Parent / Guardian Name

First NameLast Name
Phone Number

Area CodePhone Number
Patient's Email*
Does the patient require antibiotics prior to dental treatment?

YesNo
Patient Communication - please select from the following:

Patient will call for appointmentPlease call patient
Referring Doctor's Information
Referred By

First NameLast Name
Phone Number

Area CodePhone Number
Office Email*
Referred For The Following

Complete Periodontal EvaluationGingival RecessionCone Beam Computed Tomography (CBCT)Ridge AugmentationImplantsFrenectomyGingival Contouring for CosmeticsCrown-lengtheningIntra-oral ScanBiopsyExtractionsOther
For Gingival Recession, please indicate which area/tooth:
For Cone Beam Computed Tomography, please indicate which area/tooth:
For Ridge Augmentation, please indicate which area/tooth:Implants
For Implants, please indicate which area/tooth:Implants
For Frenectomy, please indicate which area/tooth:Implants
For Gingival Contouring for Cosmetics, please indicate which area/tooth:Implants
For Crown-lengthening, please indicate which area/tooth:Implants
For Intra-oral Scan, please indicate which area/tooth:Implants
For Biopsy, please indicate which area/tooth:Implants
For Extractions, please indicate which area/tooth:Implants
How will radiographs or clinical photos be obtained by our office?

Being MailedGiven To PatientPlease TakeNo X-RayUpload it here
Please upload radiographs or clinical photos, if applicable:

Browse Files

Cancelof
If images are attached, what date were they taken?
Periodontal Treatment Completed in Your Office:

Plaque Control InstructionRoot PlaningPeriodontal Maintenance TherapyProphylaxis and Gross Scaling
Is there any restorative dentistry that needs to be completed:
Additional Case Notes:
Should be Empty:

Patient Information

Referring Doctor's Information