Periodontal Referral

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

Phone (512) 346-6097 · Fax (512) 346-8135 · austinperiodontal.com · Rated 5.0 on Google from 127 reviews (September 2026)

Referring Office

Doctor

Practice

Phone

Office fax

Office email (encrypted delivery)

Referral date

Send report byFax Encrypted email Portal

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 Faxed 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