Referral Form

    REFERRAL FORM


    MaleFemale

    Consultation is requested for:

    Crowding/Spacing
    Class II Malocclusion
    Class III Malocclusion
    Excessive Overjet
    Excessive Overbite
    Congenitally Absent Teeth
    Other

    Comprehensive Periodontal Exam
    Specific Periodontal Exam

    Reason for Referral
    Consultation
    Root Canal Therapy
    Re-Treatment
    Periapical Surgery
    Vital Pulp Therapy

    Implantology Only (refer back for prosthesis)
    Implantology & Restorative

    DICOM
    DCM

    Indication

    For Implant Planning:
    Radiographic Stent Provided
    Measurements Needed (+$35 per Quad)
    For Surgery:
    For Endodontics:
    Root Fracture
    Dental Trauma
    Perforation
    Resorption
    Apical Pathosis
    Canal Anatomy
    For Pathology Assessment:

    Additional:

    Fully Guided
    Pilot Hole(s) Only
    Implant System: Astra
    Implant System: Other

    Radiographs Enclosed:

    FMX
    PA
    BW
    Panorex
    CEPH

    Relevant Medical History:

    Assignment is NOT accepted, although claims will be submitted electronically on behalf of the patient.