Referral Forms

We know you care about your patients and we are honored that you have chosen us to help improve the health of your beloved patients. Our vision is to be the periodontal specialty practice with the highest standard of care in our community. To ensure that your patient has an optimal and effortless visit, we ask that you provide the following information to streamline the patient experience.

Referral Form

Reason for Referral

Please specify the following:

• Why the evaluation is needed: (ex. periodontal disease, recession, Implant evaluation for desired restoration, periodontal status prior to restorative work, etc…)
• Which teeth are involved: list teeth numbers if localized, or list generalized for multiple teeth
• Implants: please specify your preferred implant system (Straumann or Nobel), and the planned implant restoration (ex. cement vs screw retained crown, implant overdenture vs. hybrid, etc.)
• Patient Name and Phone Number

Full Mouth Radiographs

• A full mouth series of radiographs are needed to properly diagnose periodontal conditions.
  • If an FMX is not available, or if radiographs are not diagnostic due to poor quality images or printed poorly, the patient will be scheduled for a full mouth series of radiographs at our office.
• Digital Radiographs: Please send all recent digital radiographs electronically to our Florence and Highland Heights Team. If digital radiographs cannot be sent, please print radiographs on photographic paper with an inkjet printer to ensure minimal loss of radiographic diagnostic information.
• Film Radiographs: Please send the films with the patient to bring with them to their appointment at our office.

Photographs

If available, please send any digital dental photographs that may improve diagnosis and treatment planning.