Demographic Information

PATIENT INFORMATION
Name:

Guardian (if applicable):

Address:

Gender:
MaleFemale

Email:

Phone / Date of Birth:

REFERRING DOCTOR
Name:

Office / Office Phone:

Please call patient to schedulePatient will call to schedule

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)?
YesNo

Preprosthetic (Alveoplasty, frenectomy, etc.)
Yes

Trauma
Yes

TMD / Facial Pain
Yes

Pathology / Biopsy:
Yes

Cleft Lip and Palate:
Yes

Exposure / Bond:
Yes

Orthognathic Surgery:
Yes

Other:

DENTAL IMPLANTS
Implant Type:
StraumannAstraNobelOther

Digital Implant Impression:
YesNo

Lab:

Full Arch:
Full Arch:
FixedRemovableUpperLower

Would you like us to fabricate and insert the immediate provisional?
YesNo

MANAGEMENT, MEDICAL OR TREATMENT COMMENTS: