Patient Name: Home Phone: Work Phone: Periodontal/ Implant evaluation: Repair Recession in sites: Crownlengthen teeth: Laser repair of cracked teeth: Apicoectomy on teeth: The restorative treatment plan is: I will complete: Scaling and root planing, Tooth preparation and temporaries, Endodontic treatment, Temporary removable prosthesis, Other before the periodontal/implant treatment begins Notes: Radiographs: Please take, Being mailed, Given to patient Referring Doctor: Phone: Email:
