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:
Submit