Referral Form - Periodontal | Village Walk Family Dental

Referring Doctor

Office

Patient Name

Patient D.O.B.

Patient Gender

M F Other

Patient Address

Patient City

Patient Postal Code

Cell Phone

Home Phone

Consultation is requested for:

Comprehensive Periodontal Exam $350 – This includes a consultation and a full comprehensive periodontal examination Specific Periodontal Exam $200 – This included a consultation and a full specific examination for a specific periodontal issue

Explain Reason for Referral:

Last Recall including Scaling/Root Planing

Future Recall including Scaling/Root Planing

DDS Diagnosis:

Additional Information (ie. reports/findings from outside source)

Relevant Medical History:

Referral form

PAN & Relevant x-rays

Date of x-rays

IO Photos & Patient Profile Pic – Must be included for recession referrals (if available)

Tracker Patient Info and Med HX- including notes from the date of the appointment that prompted referral

Perio Charting – Must be included for comprehensive referrals

Outside referral reports (ie. CBCT, ENDO, Perio, etc.)

Cancellation Policy - signed by patient

Referral form

Referral Form Completed by:

Patient Initials

Patient Acknowledges of Non Assignment and Consultation Fees

File Upload

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Tuesday	8:00am – 4:00pm
Wednesday	8:00am – 4:00pm
Thursday	9:00am – 5:00pm
Friday	9:00am – 3:00pm
Saturday (1/month)	9:00am – 1:00pm
Sunday	Closed

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