EPIC PERIO Dental Professionals Referral Form

Dental Professionals Referral Form
Patient Name*

First Last
Date*

MonthDayYear
Date
Patient's Home Phone Number

Area CodePhone Number
Patient's Work Phone Number

Area CodePhone Number
Patient's Cell Phone Number

Area CodePhone Number
Email
example@example.com
Reason for Examination

EmergencyGeneralized PeriodontitisLocalized PeriodontitisFull Mouth ImplantsIndividual ImplantsOrthodontic Teeth UncoveringOrthodontic Teeth FrenectomyOrthodontic Teeth FiberotomyCrown LengtheningGuided Tissue RegenerationOcclusion ConcernsSoft Tissue GraftPathologyGingival Contouring for Cosmetics/Health
Radiographs (provide dates)

Being mailed or emailedGiven to the patientPlease takeNo x-rays
Upload Radiographs PDF

Browse Files

Cancelof
Full Mouth Series

MonthDayYear
Date
Periapical(s)

MonthDayYear
Date
Bitewing(s)

MonthDayYear
Date
Panoramic

MonthDayYear
Date
3-D Conebeam Cat Scan

MonthDayYear
Date
Anticipated Restorative Treatment

MonthDayYear
Date
Comments
Dr. Name

First NameLast Name
Date

MonthDayYear
Date
Required*

Patient will call to schedule appointmentPlease call patient to schedule appointment
Select A Doctor*

Dr. BarssDr. Jensen
Please note: This examination will be scheduled for one hour to adequately compile medical, clinical, and past dental information. Codes used include: D0180 plus any x-rays determined to be required. There is a fee for this service.
Should be Empty: