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PATIENT PHONE NUMBER
DOCTOR OF CHOICE---DIEGO A. CAMACHOJERRY H. ROSENBAUM
(Please check one):
Please call patient for appointment.
Patient will call your office for appointment.
(Please check all that apply):
1. How long has he/she been a patient?
2. When did you first recommend he/she see a periodontist?
3. Has a prophy been done at GP's office in the last 6 months?yesno
4. You used code D4341 or D4342 within the last two years?yesno
5. What recall cycle has the patient been on?
Implants Tooth #(s)
Soft Tissue Graft - Tooth #(s)
Crown Lengthening Procedure - Tooth #
Periodontal Disease Treatments
Tooth Extraction #(s)
Periodontal Surgery For Orthodontics
Wisdom Teeth Evaluation:
2. When did you first recommend he/she see a surgeon?
Will be mailedWill be emailedIs needed, please take filmsPatient will bring
Crowns (Tooth #s):
Upon patients completion of periodontal treatment, please call us to schedule an appointment for him/her with our office.
1. Is the patient physically handicapped?yesno
2. Is premedication needed?yesno
3. What is the patients apprehension level?RelaxedNormal AmountVery AnxiousOther