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Periodontal Email Referral Form

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Complete Periodontal Evaluation
REASON FOR REFERRAL
RADIOGRAPHS
Implants
Gingival Recession
IMPLANTS
Graft For Root Coverage
Crown Lengthening
SURGICAL TEMPLATE
Guided Tissue Regeneration
Gingival Contouring For Cosmetics
Ridge Augmentation
Other

 

PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE
Plaque Control Instruction
Prophylaxis and Gross Scaling
Root Planing
Periodontal Maintenance Therapy

Have you advised the patient of the possibility of extraction of any teeth? If yes, which tooth numbers?

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Is there any restorative dentistry that needs to be completed?

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98 East Main Street, Babylon, New York 11702
Phone (631) 661-6633 · Fax (631) 661-6645
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David R Scharf DMD is a Periodontist in Babylon on Long Island. His Periodontal Services include dental implants, tooth cleaning, perioscopy, gingivectomy, periodontics, plaque removal, and soft tissue reconstruction. Serving the Babylon, Long Island, New York area.