Form Trial




INSTRUCTIONS

Fill in the fields on the form by using the tab key to move from field to field. When you have completed the form, click on the SUBMIT FORM button at the bottom of the page. Once you submit this form you will have the option to upload up to 5 x-rays images.

 

PATIENT INFORMATION






















Does the patient require antibiotics prior to dental treatment?
YesNo

 

REFERRING DOCTOR INFORMATION










 

OTHER PROCEDURES

CONSULTATION

RADIOGRAPHS/CLINICAL PHOTOS


Extraction (see tooth chart below)

Alveoloplasty

Biopsy

Incision and Drainage

Lesion Evaluation

Exposure

Hard Tissue

Infection

Expose and Bond

Soft Tissue

Frenectomy

Apicoetomy

Other:

TMJ

Implants

Orthognathic Evaluation

Pre-Prosthetic

Cleft Lip and Palate

Cosmetic


Ridge Augmentation

Oral / Facial Lesion

Bone Grafting

Other:

IMPLANTS


SURGICAL TEMPLATE


Being Mailed

Given to Patient

Please Take

No X-Ray

Upload X-Ray Images: Once you submit this referral form, the confirmation box will give you the option to upload up to 5 x-rays. (must be a common image file type: .jpg, .bmp, .tiff, .png, .pdf, word document).

If X-Rays are attached, what date were they taken:

 

EXTRACTIONS

RIGHT


1



2



3



4



5



6



7



8



9



10



11



12



13



14



15



16
LEFT


32


31


30


29


28


27


26


25


24


23


22


21


20


19


18


17

EXTRACTIONS

RIGHT


A



B



C



D



E



F



G



H



I



J
LEFT


T


S


R


Q


P


O


N


M


L


K




 

COMMENTS


 

Once this form is submitted, you will have the option to PRINT a copy of this submitted form in a PDF format.

Office hours by appointment
© 2018 John Kim, DMD | 3102 Niles Road St. Joseph, MI | 269-429-7122
Call Now
Directions