periosolution.com.hk

perioSolution Periodontal and Implant Clinic

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Periodontal Referral Form

(Download Form)

 

Patientís Name: ____________________________

Contact Telephone No.:         _____________________________

Referring Dentistís Name: _____________________________

Office Telephone No.: _____________________________

 

Referring for the following condition: _______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

 

He/She has been a patient in our practice since __________

Relevant treatment received recently: _______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

 

We have planned the following treatment for the patient after completion of your periodontal treatment: _______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

 

_____  Please continue to provide periodontal maintenance for patient after completion of active treatment

_____  Please refer patient back for periodontal maintenance after completion of active treatment

 

 

 

 

 

Dentistís Signature: _________________________                  Date: _____________________



 



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