For Referring Offices - Fort Lauderdale Periodontics and Implant Dentistry

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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

Patient Name*
Phone*
Email*
Doctor of Choice
Appointment:
- 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?
- Yes
- No
4. You used code D4341 or D4342 within the last two years?
4. You used code D4341 or D4342 within the last two years?
- Yes
- No
5. 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...
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- Periodontal Disease Treatments
Details...
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- frenectomy/gingivectomy
Details...
- Tooth Extraction #(s)
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- Periodontal Surgery For Orthodontics
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- 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 mailed
- Is needed, please take films
- Will be emailed
- Patient 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?
- Yes
- No
Comments...
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?
- Yes
- No
Comments...
Comments...
2. Is premedication needed?
2. Is premedication needed?
- Yes
- No
Comments...
Comments...
3. What is the patients apprehension level?
3. What is the patients apprehension level?
- Yes
- No
Comments...
Comments...
PLEASE SEND ADDITIONAL:
- Referral Pads
Dr.

Request an Appointment

Office Hours

Monday: 8am-6pm
Tuesday: 7am-6pm
Wednesday: 7am-6pm
Thursday: 7am-6pm
Friday: 8:30am-5pm
Saturday: by appointment only
Sunday: by appointment only

OUR OFFICE IS LOCATED AT:

PHONE/FAX:

Appointment:

Wisdom Teeth Evaluation:

A COMPLETE SERIES (Please check one):

ANTICIPATED TREATMENT PLAN: WHAT WOULD YOUR IDEAL ANTICIPATED TREATMENT PLAN BE?

TO HELP US BETTER PREPARE:

PLEASE SEND ADDITIONAL:

Schedule Your Appointment Today

Request an Appointment

Office Hours