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Practice Name

Fairfield County Implant & Periodontics


Main Content

Instructions

Fill in the fields on the form by using the tab key to move from field to field. When you have completed the form, click on the SUBMIT FORM button at the bottom of the page. Once you submit this form you will have the option to upload up to 5 x-rays images.


Patient Information

Does the patient require antibiotics prior to dental treatment?
Yes No


Referring Doctor Information


Other Procedures

  • Extraction (see tooth chart below)
  • Alveoloplasty
  • Biopsy
  • Incision and Drainage
  • Lesion Evaluation
  • Exposure
  • Hard Tissue
  • Infection
  • Expose and Bond
  • Soft Tissue
  • Frenectomy
  • Apicoetomy
  • Restorative crown lengthening
  • Esthetic crown lengthening
  • Smile Analysis
  • Pre-orthodontic evaluation
  • Sinus grafting
  • Pre-prosthetic surgery
  • Accelerated orthodontics
  • Non-surgical periodontal therapy
  • Facial pain
  • Other:

Consultation

  • TMJ
  • Orthognathic Evaluation
  • Pre-Prosthetic
  • Cleft Lip and Palate
  • Cosmetic
  • Ridge Augmentation
  • Oral / Facial Lesion
  • Bone Grafting
  • Periodontal evaluation
  • Crown lengthening
  • Dental implants
  • Recession/Soft tissue grafting
  • Oral pathology
  • CBCT scan evaluation
  • Other:
  • IMPLANTS
  • SURGICAL TEMPLATE

Radiographs/Clinical Photos

  • Being Mailed
  • Given to Patient
  • Please Take
  • No X-Ray

Upload X-Ray Images

Once you submit this referral form, the confirmation box will give you the option to upload up to 5 x-rays. (must be a common image file type: .png, .bmp, .tiff, .png, .pdf, word document).

If X-Rays are attached, what date were they taken:  

Extractions

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Comments

 

Once this form is submitted, you will have the option to print a copy of this submitted form in a PDF format.