Fill The Referral Form

3901 Dutchman’s Lane, Suite 201 Louisville, KY
Phone (502) 268-4840
advancedimplantcenters.com

Doctor-Patient Info:

Referral Date:

Office Phone: Please Enter Office Phone Please Enter Valid Phone

Patient Name: Please Enter Patient Name

Referring Doctor: Please Enter Referring Doctor

Patient Phone: Please Enter phone number Please Enter Valid Phone

Appointment Information: This time is reserved specifically for you. If, by necessity, you must reschedule your appointment for surgery, please notify us at least one day in advance.

For Implant Referrals

Robert Schroering, DMD

Diplomate, American Board of Oral Implantology, Advancement of Dental Education & American Academy of Implant Dentistry

Extractions#

TMJ

Pathology

Expose and Bond Ortho Bracket

Other

Additional Remarks:

Special Instructions for General Anesthesia Patients:

Patients who receive general anesthesia should not have ANY FOOD OR DRINK, including water, for at least 6 hours prior to surgery.

You must arrange for someone to drive you home after surgery. Your driver must come into the office to pick you up.

Please bring this referral with you to your appointment.

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Periodontal Disease

Gingival Recession #

Crown Lengthening #

Frenectomy

Other

Extractions / Socket Graft #

Pathology

Implant Evaluation For:

Teeth #:

Please place stock abutment(s)

Referring dentist will place abutment

Has the patient received quadrant scaling and root planing?

YES

DATE:

X-RAYS:

Does the patient have a recent FMX you can provide us?

YES