Referral Form Form

Peter A. Russo, D.D.S., Inc.

Robert Lacrampe D.D.S.

Periodontics and Implant Surgery

18800 Main Street, Suite #201 • Huntington Beach, CA 92648 • (714) 842-2515

Referring Dentist:

Introducing:

Date:

My patient requires:

A complete periodontal examination to include:

Implant consultation

Ridge augmentation

Peri-implantitis

A limited periodontal examination (circle area/teeth)

Crown lengthening

Soft tissue graft

RIGHT

LEFT

Symptoms:

pockets

mobility

bone loss

recession

inadequate attached gingiva

bleeding

acute periodontal abscess

other

Please contact our office if you have a history of endocarditis, prosthetic heart valve or other device, or prosthetic joint replacement. we may need to contact your physician to determine if antibiotic premedication is necessary before your appointment.

The patient is:

New to my practice

No.

years in my practice

Attendance has been:

regular

irregular

Scaling/root planing

has

has not been completed

is scheduled

will be scheduled

My plan for the following restorative/prosthetic dentistry

has

has not been discussed with patient

Please call:

Before patient consultation

After consultation

Please mail or email recent full mouth xrays

Patient's concerns & motivations:

Function

Eating

Social

Quality care

Esthetics

Fear

Cost

Time

Comments / Significant Medical History

email: staff@implantsandgums.com

Patient Validation:

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