Eldridge Dental

Ali Sajadi, DDS, MSD

6370 N. Eldridge Pkwy, Suite B, Houston, TX 77041

P: (713) 983-0099

https://www.eldridge-dent.com/

Please email X-rays to:eldridgedentaltx@yahoo.com
Date

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PATIENT INFORMATION
First name*
Last name*
DOB

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REFERRING DOCTOR INFORMATION
Referred by
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REASON FOR REFERRAL (please check):

Complete Periodontal Evaluation(Early)Complete Periodontal Evaluation(Moderate)Complete Periodontal Evaluation(Advanced)Guided Tissue Regeneration (GTR)Gingival Contouring for Cosmetic RestorationCrown LengtheningRidge AugmentationGrafting for root coverageComplete Oral Surgery EvaluationExtractionsWisdom TeethImplant ConsultationSurgical template/guide
PLEASE INDICATE TOOTH NUMBER(s):

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Please indicate what periodontal treatment has been completed in your office:

Plaque control instructionsScaling & root planing (SRP)No periodontal treatment renderedProphylaxis/Gross scalingPeriodontal maintenance (PMT)
Have you advised the patient of the possibility of extractions? If so, which tooth number(s)?
IS THERE ANY RESTORATIVE DENTISTRY THAT NEEDS TO BE COMPLETED?

YesNo
If so, what is planned?
COMMENTS
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PATIENT INFORMATION