PI referral pad - Bell Harbour Dental · Patient’s Name _____ Date _____ Phone _____ Email _____...
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Patient’s Name ____________________________________________ Date _______________ Phone _______________________________ Email __________________________________ Referring Doctor_______________________________________________________________ No Cover Letter Needed. Please Fax to 206-625-9658 PATIENT INFORMATION Comprehensive Exam & Treatment _____ Limited Exam & Treatment ___________ Crown Lengthening _________________ Gingivectomy ______________________ Lingual Tissue Grafting_______________ Soft Tissue Grafting ______________ Pocket Reduction ________________ Periodontal Bone Grafting _________ Pre-Ortho Perio Eval ______________ Other__________________________ PERIODONTAL THERAPY Extraction & Site Preservation _________ Implant Placement (Sites: ____________ ) Immediate Implant Placement & Temp Crown (Sites: ________________ ) Sinus Augmentation _____________ Ridge Augmentation _____________ Other__________________________ IMPLANT THERAPY Extractions/3rd Molar Ext. ___________ Soft/Hard Tissue Biopsy _____________ Tooth Exposure for Orthodontics _____ Frenectomy ______________________ IV Sedation _____________________ Cone Beam / CAT Scan ____________ Other__________________________ OTHER SERVICES Patient will bring Emailed to office ([email protected]) Comments ___________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Mailed to office New Radiographs Needed RECENT FULL MOUTH RADIOGRAPHS Please Indicate Tooth Numbers 2623 2nd Avenue Seattle, WA 98121 206-625-9358 Fax 206-625-9658 PerioInnovations Implant Dentistry and Innovative Periodontics Adrian P. Pawlowski, DDS, MSD Diplomate of the American Board of Periodontology
Transcript of PI referral pad - Bell Harbour Dental · Patient’s Name _____ Date _____ Phone _____ Email _____...
Patient’s Name ____________________________________________ Date _______________
Phone _______________________________ Email __________________________________
Referring Doctor_______________________________________________________________
No Cover Letter Needed. Please Fax to 206-625-9658
PATIENT INFORMATION
Comprehensive Exam & Treatment _____
Limited Exam & Treatment ___________
Crown Lengthening _________________
Gingivectomy ______________________
Lingual Tissue Grafting_______________
Soft Tissue Grafting ______________
Pocket Reduction ________________
Periodontal Bone Grafting _________
Pre-Ortho Perio Eval______________
Other__________________________
PERIODONTAL THERAPY
Extraction & Site Preservation _________
Implant Placement (Sites: ____________ )
Immediate Implant Placement & Temp Crown (Sites: ________________ )
Sinus Augmentation _____________
Ridge Augmentation _____________
Other__________________________
IMPLANT THERAPY
Extractions/3rd Molar Ext. ___________
Soft/Hard Tissue Biopsy _____________
Tooth Exposure for Orthodontics _____
Frenectomy ______________________
IV Sedation _____________________
Cone Beam / CAT Scan ____________
Other__________________________
OTHER SERVICES
Patient will bring
Emailed to o�ce ([email protected])
Comments ___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Mailed to o�ce
New Radiographs Needed
RECENT FULL MOUTH RADIOGRAPHS
Please Indicate Tooth Numbers
2623 2nd AvenueSeattle, WA 98121
206-625-9358Fax 206-625-9658
PerioInnovationsImplant Dentistry and Innovative Periodontics
Adrian P. Pawlowski, DDS, MSDDiplomate of the American Board of Periodontology
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