Referring Doctor Form

Referral Form

Referral Date

Office Information

Patient is new to my practice

How long have they been your patient?

Referring Dr. would like for Dr. Woodyard to call them after the patient’s exam?

Does the patient currently have pain? Swelling? Taking antibiotics?

Appointment Date

Call Patient to Schedule appointment?

Referred For

Periodontal Evaluation

When did you first recommend he/she see a periodontist?

Has a periodontal exam (probing) been done in the last year?

Has the patient had scaling and root planing (CDT code D4341 or D4342) within the last 5 years?

What recall cycle has the patient been on?

Date of last maintenance recall?

Dental Implants
Tooth Removal and Socket Preservation
Crown Lengthening
Soft Tissue Graft
Frenuloplasty/Frenectomy
Other

DIAGNOSTIC RADIOGRAPHS (Please indicate if current images are available)

Select all applicable (hold Command/Control to select more than one item)

We encourage you to contact us with any questions or comments you may have

Make an appointment today and we will give you a reason to smile!





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