Date
Patient’s name: 
Patient’s telephone#:
Referred by Dr.

Treatment already completed in your office:

• Plaque control instruction
• Prophylaxis and gross scaling
• Root planing
• Periodontal maintenance therapy
• Invisalign

Have you advised the patient of the possibility of extraction of any teeth?
If yes, which teeth?

The following examination is requested:

• Comprehensive orthodontic examination and treatment
• Comprehensive periodontal examination and treatment
• Crown lengthening, tooth #
• Extraction on tooth #
• Gingival contouring for cosmetics on tooth #
• Gingival grafts on tooth #
• Guided tissue regeneration and bone graft on tooth #
• Implant evaluation at area #
• Orthodontic forced eruption on tooth #
• Ridge augmentation at area #
• Root coverage on tooth #
• Other:

Surgical template:

• will be provided by restorative dentist
• will be provided by periodontist (Dr. Hsieh)

Special concerns or comments:

Radiographs:

• Please take radiographs as needed and send duplicates
• Radiographs available
• Please call or e-mail for radiographs
• Patient was given radiographs
• The radiograph was mailed to Scappoose Dental Specialty clinic

Your TEL:
Your e-mail:

Most of all, thank you very much for your referral!
We will take good care of your patients!