For Referring Offices: OUR OFFICE IS LOCATED AT: 3037 East Commercial Blvd Ste A Fort Lauderdale, FL 33308. PHONE/FAX: 954-772-3600 (office phone) 954-772-3663 (fax) Patient Name*Phone*Email* Doctor of ChoiceDr. Diego A. CamachoDr. Jerry H. RosenbaumAppointment: Please call patient for appointment. Patient will call your office for appointment. 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?3. Has a prophy been done at GP's office in the last 6 months? YesNo4. You used code D4341 or D4342 within the last two years?4. You used code D4341 or D4342 within the last two years? YesNo5. What recall cycle has the patient been on?Implants Tooth #(s) Implants Tooth #(s) Details... Soft Tissue Graft - Tooth #(s) Details...Crown Lengthening Procedure - Tooth # Crown Lengthening Procedure - Tooth # Details...Untitled Periodontal Disease Treatments Details...Untitled frenectomy/gingivectomy Details... Tooth Extraction #(s) Untitled Periodontal Surgery For Orthodontics Untitled Other Wisdom Teeth Evaluation:1. How long has he/she been a patient?2. When did you first recommend he/she see a surgeon?A COMPLETE SERIES (Please check one): Will be mailedIs needed, please take filmsWill be emailedPatient will bring 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 ANTICIPATED TREATMENT PLAN: WHAT WOULD YOUR IDEAL ANTICIPATED TREATMENT PLAN BE? Crowns (Tooth #s):Bridges (locations):Crowns (Tooth #s):Bridges (locations):3. HAS A PROPHY BEEN DONE AT GP'S OFFICE IN THE LAST 6 MONTHS?3. HAS A PROPHY BEEN DONE AT GP'S OFFICE IN THE LAST 6 MONTHS?YesNoComments...Upon patients completion of periodontal treatment, please call us to schedule an appointment for him/her with our office. Upon patients completion of periodontal treatment, please call us to schedule an appointment for him/her with our office. TO HELP US BETTER PREPARE:1. Is the patient physically handicapped?1. Is the patient physically handicapped? YesNoComments...Comments...2. Is premedication needed?2. Is premedication needed?YesNoComments...Comments...3. What is the patients apprehension level?3. What is the patients apprehension level? YesNoComments...Comments...PLEASE SEND ADDITIONAL: Referral Pads Dr.