Referring Doctors

Referral Form

Periodontal Email Referral Form

Patient Name:
Referred By:
Phone:
Email:

Complete Periodontal Evaluation

REASON FOR REFERRAL	RADIOGRAPHS
Implants
Gingival Recession
Graft For Root Coverage
Crown Lengthening
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?

Tooth #s:

Is there any restorative dentistry that needs to be completed?

COMMENTS:

Periodontist Dr. David Scharf, Gum Dentist in Long Island NY, offers treatment of Gum Disease, including Laser Periodontal Therapy,
Placement of Dental Implants, Teeth in an Hour, Partial Dentures & Gum Reconstruction.
Address: 98 East Main Street • Babylon, NY 11702 • Telephone: 631-661-6633 • Fax: 631-661-6645