Referral Form

Reason For Referral: Required

Periodontal Evaluation

Bone Grafting

Gingival Grafting

Implant

Emergency Visit

Crown Lengthening

Root Planing

Extraction

Radiographs (Please e-mail): Required

Given to Patient

Please Take

Being Mailed

Last FMX/PA/BW Radiograph

Have you advised the patient of the possibility of extraction of any teeth? Required

Yes

No

Do you have any restorative plans for treating this case?

Yes

No

Would you like a phone call as soon as your patient is seen? Required

Yes

No

Edithann J Graham, DMD, MS
Megan Smith, DMD