Demographic Information

    PATIENT INFORMATION

    Referral to:

    Dr. Scott MartynaDr. Gordon WongNo Preference

    Name:

    Guardian (if applicable):

    Address:

    Sex (for insurance purposes only):

    MaleFemale

    Pronouns (optional):

    Email:

    Phone / Date of Birth::

    REFERRING DOCTOR

    Name:

    Office / Office Phone:

    Radiographs / Photos:

    EmailedMailedPatient Will BringPlease Take New Ones

    Referring Information

    Tooth #'s or areas to be treated (please also indicate on diagram):

    RIGHT

    Yes

    18

    Yes

    17

    Yes

    16

    Yes

    15

    Yes

    14

    Yes

    13

    Yes

    12

    Yes

    11

    Yes

    21

    Yes

    22

    Yes

    23

    Yes

    24

    Yes

    25

    Yes

    26

    Yes

    27

    Yes

    28

    48

    Yes

    47

    Yes

    46

    Yes

    45

    Yes

    44

    Yes

    43

    Yes

    42

    Yes

    41

    Yes

    31

    Yes

    32

    Yes

    33

    Yes

    34

    Yes

    35

    Yes

    36

    Yes

    37

    Yes

    38

    Yes

    LEFT

    RIGHT

    Yes

    55

    Yes

    54

    Yes

    53

    Yes

    52

    Yes

    51

    Yes

    61

    Yes

    62

    Yes

    63

    Yes

    64

    Yes

    65

    85

    Yes

    84

    Yes

    83

    Yes

    82

    Yes

    81

    Yes

    71

    Yes

    72

    Yes

    73

    Yes

    74

    Yes

    75

    Yes

    LEFT

    PROCEDURE(S) OR CONSULTATIONS REQUESTED

    Extractions:

    Yes

    Discuss replacement with dental implant(s)?

    Preprosthetic (Alveoplasty, frenectomy, etc.)

    Yes

    Trauma

    Yes

    TMD

    Yes

    Pathology / Biopsy:

    Yes

    Cleft Lip and Palate:

    Yes

    Exposure / Bond:

    Yes

    Orthognathic Surgery:

    Yes

    Other:

    DENTAL IMPLANTS

    Implant Type:

    Digital Implant Impression:

    Lab:

    Full Arch:

    Full Arch:

    FixedRemovableUpperLower

    Immediate provisional will be provided by

    MANAGEMENT, MEDICAL OR TREATMENT COMMENTS:

    Relevant Images or Documents: