EPIC Perio Dental Professionals Referral Form

Dental Professionals Referral Form
Patient Name *

First Last
Date *

Month Day Year
Date
Patient's Home Phone Number

Area Code Phone Number
Patient's Work Phone Number

Area Code Phone Number
Patient's Cell Phone Number

Area Code Phone Number
Email
example@example.com
Reason for Examination

Emergency Generalized Periodontitis Localized Periodontitis Full Mouth Implants Individual Implants Orthodontic Teeth Uncovering Orthodontic Teeth Frenectomy Orthodontic Teeth Fiberotomy Crown Lengthening Guided Tissue Regeneration Occlusion Concerns Soft Tissue Graft Pathology Gingival Contouring for Cosmetics/Health
Radiographs (provide dates)

Being mailed or emailed Given to the patient Please take No x-rays
Upload Radiographs PDF

Browse Files

Cancel of
Full Mouth Series

Month Day Year
Date
Periapical(s)

Month Day Year
Date
Bitewing(s)

Month Day Year
Date
Panoramic

Month Day Year
Date
3-D Conebeam Cat Scan

Month Day Year
Date
Anticipated Restorative Treatment

Month Day Year
Date
Comments
Dr. Name

First Name Last Name
Date

Month Day Year
Date
Required *

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

Dr. Barss Dr. 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: