Doctor & Dentist Referrals

Patient Name:

Patient Age:

Patient Phone:

Referring Doctor:

Office Phone:

Office Email:

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REASON FOR REFERRAL, TREATMENT GOALS, COMMENTS:

PERIODONTAL:

 No periodontal concerns
 Previous history of periodontitis, but not currently active
 Specific periodontal concerns:
 Continued care with referring office
 Patient may be referred to periodontist

RESTORATIVE & COSMETIC:

 All pre-orthodontic restorative treatment is complete
 Pre-orthodontic treatment yet to be completed:
Post-orthodontic restorative treatment proposed:
 Veneers
 Crowns/Onlays
 Bridges
 Implants
 Other:

PATIENT MOTIVATION:

 Patient understands the need for orthodontic treatment
Patient is primarily concerned with:
 Aesthetics
 Function
 Discomfort(TMD)
 Tooth loss
 Other:
Patient is
 Highly Motivated
 Indifferent
 Apprehensive

TMD:

 Patient has no history, signs, or symptoms of TMD or related disorder
 Patient does have a history of TMD or related disorders

ORAL SURGERY:

Teeth planned for extraction:

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