Periodontal Referral

Andrew Verrett, DDS, MS · Board-certified periodontist · 7800 N Mopac Expy, Suite 310, Austin, TX 78759

Phone (512) 346-6097 · Email sarah@austinperiodontal.com · austinperiodontal.com

Referring Office

Doctor

Practice

Phone

Office email

Referral date

Call me before the plan is presentedYes

Patient

Name

Date of birth

Phone

Insurance

Interpreter neededYes, language: ________

Medical alertsAntibiotic premedication Pregnant Latex allergy Anticoagulant Antiresorptive / bisphosphonate Diabetes Allergies: ____________ Under 18 (guardian to attend)

Reason for Referral

Periodontal evaluation and treatment Gum recession / soft-tissue graft, teeth # ______ Dental implant, teeth # ______ Extraction with socket preservation, # ______ Bone graft / sinus lift Crown lengthening, tooth # ______ Peri-implantitis / failing implant Frenectomy Extraction only, no graft, # ______ Implant removal Second opinion Other: ____________________

UrgencyRoutine Within 2 weeks Same day

RadiographsEnclosed Emailed Please request

Also enclosedPerio charting Photos

Sedation requestedNitrous Oral IV

Patient told: reason for referral and specialist feeYes

Restorative plan (implants)

Implant system (Nobel Biocare unless noted)

RetentionScrew-retained Cement-retained

ProvisionalNone By your office By APA

Esthetic zoneYes

Wax-up / STL to followYes

Referring doctor signature

Date

Referring Office

Patient

Reason for Referral

Notes