Referring Doctor / Practice Information

Patient Information
Please Evaluate for:

Full periodontal evaluationLocal periodontal evaluationSoft tissue graftingBiopsyCrown lengtheningCanine exposureTooth extraction/Ridge preservactionImplant placementRidge augmentation (soft/hard tissue)Sinus lift/AugmentationSedation (intravenous or N2O + O2CBCT and Analysis

Radiographs

Tar Heel Periodontics will take new radiographs (Preferred)X-rays will be sent (indicate source)
with patientby mailby email (info@tarheelperio.com)as part of this form

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