Referring Doctors

This form is developed for your convenience, please feel free to submit as little or as much information as you would like.

We value your referral and the importance of effective communication between our offices. We will always strive to provide you with the most up to date progress of your patient’s diagnosis and treatment. Thank you for your time and referral.

Please do not hesitate to contact us if you have any questions.

Phone: 352.589.1973
Fax: 352.589.6204

Items in bold indicate required information.

 

Patient Information
First Name	*
Last Name	*
Home Phone	*
Work Phone	*
Email	* *
Address	*
City	*
State/Province	Select One Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory *
Zip Code	* *
Referring Doctor Information
First Name	*
Last Name	*
Phone	*
Email	* *
Reason For Referral
Periodontal Exam
Implants Gingival Contouring For Cosmetics Crown Lengthening Gingival Recession Ridge Augmentation Other
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Periodontal Treatment History
	No Perio. Tx. Surgery Scaling & Root Planing Other
Radiographs	Select Radiographs emailed Radiographs mailed Please take necessary radiographs
Have you advised the patient of the possibility of extraction of any teeth? If yes, which teeth numbers?
Is there any restorative dentistry that needs to be completed?
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