Patient Referral

From Dr. Date:
Patient's Name:
Referring Doctor's Diagnosis?
Please Evaluate for:

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Dental Implants
Extraction with Immediate Implant
Bone Graft Extraction Site(s)
Bone Graft Aveolar Ridge
Sinus Graft
Impacted third molars (wisdom teeth)
LASER Surgery
LASER Frenectomy
Preprosthetic Surgery
Exposure and Bonded on Bracket
Oral/Facial Infection

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