Dental Professionals Referral Form Patient Name* First Last Date* MM DD YYYY Patient's Home Phone NumberPatient's Work Phone NumberPatient's Cell Phone NumberReason for Examination Emergency Generalized Periodontitis Localized Periodontitis Full Mouth Implants Individual Implants Orthodontic Teeth Uncovering Orthodontic Teeth Frenectomy Orthodontic Teeth Fiberotomy Crown Lengthening Guided Tissue Regeneration Occlusion Concerns Soft Tissue Graft Pathology Gingival Contouring for Cosmetics/Health Radiographs (provide dates) Being mailed or emailed Given to the patient Please take No x-rays Upload Radiographs PDFFull Mouth Series MM DD YYYY Periapical(s) MM DD YYYY Bitewing(s) MM DD YYYY Panoramic MM DD YYYY 3-D Conebeam Cat Scan MM DD YYYY Anticipated Restorative Treatment MM DD YYYY Comments Dr. Name Date MM DD YYYY Required* Patient will call to schedule appointment Please call patient to schedule appointment Please note: This examination will be scheduled for one hour to adequately compile medical, clinical, and past dental information. Codes used include: D0180 plus any x-rays determined to be required. There is a fee for this service. Reach Us 3475 Plymouth Blvd. Suite 200 Plymouth, MN 55447 Phone: 763-694-6158 / Fax: 763-577-1375 info@epicperio.com Map / Directions Forms New Patient Letter Patient Registration Medical History Dental History Consent Form Navigation Home Dr. Barss Dr. Jensen Services & Info Dental Professionals
