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 #________________________________________________

Surgical template:

1. will be provided by restorative dentist
1. Will be provided by periodontist (Dr. Hsieh)
2. Orthodontic forced eruption on tooth #_____________________________________
3. Ridge augmentation at area #______________________________________________
4. Root coverage on tooth #_________________________________________________
5. Other _________________________________________________________________

Special Concerns or comments:

1. Please take radiographs as needed and send duplicates
2. Radiographs available
1. Please call or e-mail for radiographs.

q Your TEL: ______________________________________
q Your e-mail:_____________________________________

1. Patient was given radiographs
2. The radiograph was mailed to Scappoose Dental Specialty clinic.

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

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