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 (service@perioinnovations.com)

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