Jennifer Cha, DMD, MS | Leon Chen DMD, MS

Patient Referral Form

Patient Information

First Name *

Last Name *

Date

Patient's Phone *

Evening Phone

Treatment Rendered:

Scaling & Root Planning

Gross Debridement

Other Other

Remarks / Treatment Plan:

Referring Dentist

Name *

Phone *

Office Name / Address:

Office email:

Periodontal Referral

Referral is for:

Consultation Only

Consultation and Therapy

Please Check all that apply to the following:

Full Mouth Periodontal Evaluation:

Tooth Exposure, #:

Osseous Surgery:

Root Amputation or Hemisection, #:

Crown Lengthening, #:

Laser Therapy, site:

Root Coverage, #:

TX of Peri-Implantitis, #:

Gingival Graft to Increase Attachment, #:

Dental Implant Referral

Cat Scan, X-ray or Pano Only:

Cat Scan Only

X-Ray Only

Pano Only

Please Check One or More:

The patient wants to have a consultation

I would like to be present when the Drs. perform the surgery

I would like the Drs. to perform the surgical/prosthodontic phases

I would like to assist the Drs. during the prosthetic phases

I would like to use your facility for surgery and prosthetic phases

I want to do the prosthesis, refer me back with:

Healing

Final

Custom Abutment

Treatment Area:

Please Check all that apply to the following:

Diagnosis:

Mandible

Maxillary

Sinus Lift:

Unilateral-Right

Unilateral-Left

Bilateral

Bone Density:

III

Root Form Implants:

Root Form

Mini-Implant

#'s #'s

Enter the word in the image and then click Submit *
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