For Doctors

OUR OFFICE IS LOCATED AT:

3037 East Commercial Blvd Ste A Fort Lauderdale, FL 33308.

PHONE/FAX:

+1 800 603 6035
+1 800 889 9898 fax

APPOINTMENT

(Please check one):

Please call patient for appointment.

Patient will call your office for appointment.

I AM REFERRING THIS PATIENT FOR

(Please check all that apply):

Periodontal Evaluation

yesno

yesno

Implants Tooth #(s)

Soft Tissue Graft - Tooth #(s)

Crown Lengthening Procedure - Tooth #

Periodontal Disease Treatments

frenectomy/gingivectomy

Tooth Extraction #(s)

Periodontal Surgery For Orthodontics

Other

Wisdom Teeth Evaluation:

A complete series

(Please check one):

Will be mailedWill be emailedIs needed, please take filmsPatient will bring

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ANTICIPATED TREATMENT PLAN: What would your ideal anticipated treatment plan be?

3. Has a prophy been done at GP's office in the last 6 months?

yesno

Upon patients completion of periodontal treatment, please call us to schedule an appointment for him/her with our office.

TO HELP US BETTER PREPARE:

yesno

yesno

RelaxedNormal AmountVery AnxiousOther

PLEASE SEND ADDITIONAL:

Referral Pads