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Referring Dentist
Patient Name
Phone: Home
Requested specialist:
Dr. Dab
Dr. Tammsalu
Any available.
Periodontal / Implant referral - (PLEASE CIRCLE)
Requires complete periodontal exam
Implants
Sinus Lift
Soft Tissue Graft
Extraction
Crown Lengthening
Emergency (abscess)
Oral Pathology / Biopsy
Socket preservation
Ridge Augmentation/Bone Grafting
Pre-Orthodontic Tx (Graft; Frenectomy; Cuspid exposure)
Additional Comments
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