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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