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Complete Periodontal Evaluation
REASON FOR REFERRAL RADIOGRAPHS
Implants
Gingival Recession IMPLANTS
Graft For Root Coverage
Crown Lengthening SURGICAL TEMPLATE
Guided Tissue Regeneration
Gingival Contouring For Cosmetics
Ridge Augmentation
Other

PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE
Plaque Control Instruction
Prophylaxis and Gross Scaling
Root Planning
Periodontal Maintenance Therapy
Have you advised the patient of the possibility of extraction of any teeth? If yes, which tooth numbers?
Tooth #s:
Please enter the number of images that you are including as attachments here:
 
Is there any restorative dentistry that needs to be completed?  
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Periodontal ProceduresDental ImplantsCosmetic EnhancementPatient RegistrationPatient InformationReferring Doctors
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