Referral Form REFERRAL FORM Referring Doctor (required) Office (required) Patient (required) Date of Birth Gender MaleFemale Address (required) City (required) Postal Code(required) Home Phone (required) Cell (required) Email Address (required) Consultation is requested for: Orthodontic (Initial Consult: No Charge) - include with Referral Form: PAN; Patient Info Crowding/Spacing Class II Malocclusion Class III Malocclusion Excessive Overjet Excessive Overbite Congenitally Absent Teeth Other Other (Please Specify) Periodontal (Consult: $200-$225) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx; Perio Charting; Cancellation Policy-signed Comprehensive Periodontal Exam Specific Periodontal Exam Other (Please Specify) Last Recall including Scaling/Root Planing Future Recall including Scaling/Root Planing Endodontics (Consult: $150) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx Tooth # Reason for Referral Consultation Root Canal Therapy Re-Treatment Periapical Surgery Vital Pulp Therapy Other (Please Specify) DDS Diagnosis: Treatment Provided by Referring DDS: Antibiotics Prescribed: Additional Comments: Oral Surgery (Consult: $200) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx Procedure Comments: Implant Consultation (Consult: $200) - Include with Referral Form:PAN & Xrays; Patient Info; Med Hx Implantology Only (refer back for prosthesis) Implantology & Restorative Comments: CBCT (Fee: $350) Please provide medical history and relevant radiographs with referral. Please select file format, and indication for CBCT below File Format for CBCT (Default is DICOM, if unsure choose DICOM): DICOM DCM Do you want CBCT and Report sent to any additional email addresses besides the referring office? If so, provide email: Rush Radiology Report? (Average turnaround is approximately 3 weeks): ---No Rush12-17 days (+$25)7-12 days (+$50)3-6 days (+$75)1-2 days (+$100)STAT (+$150) If rush is needed, date needed by: Indication For Implant Planning: Implant Locations: Radiographic Stent Provided Measurements Needed (+$35 per Quad) For Surgery: Tooth #/Location For Endodontics: Tooth #/Location Root Fracture Dental Trauma Perforation Resorption Apical Pathosis Canal Anatomy For Pathology Assessment: Area Clinical Signs and Symptoms Differential Diagnosis Additional: Surgical Guide Fabrication (Fee: $750 per arch which includes sleeve for 1 implant, plus $100 per additional implant in same arch Fully Guided Pilot Hole(s) Only Implant System: Astra Implant System: Other Implant Tooth# Prosthetic Plan: Surgery Date (if booked): Additional Comments Other: (Consult: $I.C.) 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.