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Referring Dentists
New Patient Referral Form
Referring Dentist's Name
First Name
*
Last Name
*
Referring Dentist's Phone
Phone
*
Patient's Name
First Name
*
Last Name
*
Patient's Phone
Phone Number
*
Patient Is
New
Returning
Patient Is Being Referred For
Dental Implants
Periodontal Therapy
Crown Lengthening
Gum Recession
Frenectomy
Tissue Grafting
Other
Hyegiene Interval
3 to 4 Months
6 Months
12 Months
Sporatic
Has the Patient Received Quadrant Scaling and Root Planing?
Yes
No
If yes, when?
Did the patient have x-rays taken that you can provide us?
Yes
No
If yes, what kind of x-rays and the date they were taken?
We appreciate your staff sending these x-rays to us. By what method will they be arriving?
Email
US Postal Service
With The Patient
Are you requesting a Cone Beam CT?
Yes
No
If yes, area of concern?
Do you wish for Dr. Bradshaw to do
Occlusal Adjustment
Bite Guard
Other
Who will place the abutment?
Dr. Bradshaw
Referring Doc
Type of abutment preferred?
Custom
Standard
Form Download
Download the Periodontal Exam Referral Form and Submit via Fax
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