3901 Dutchman’s Lane, Suite 201 Louisville, KY
Phone
(502) 268-4840
advancedimplantcenters.com
Referral Date:
Office Phone:
Patient Name:
Referring Doctor:
Patient Phone:
Extractions#
TMJ
Pathology
Expose and Bond Ortho Bracket
Other
Additional Remarks:
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32
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A
B
C
D
E
F
G
H
I
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Q
P
O
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K
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
NO
DATE:
X-RAYS:
Does the patient have a recent FMX you can provide us?
YES
NO
DATE:
Your Restorative Plans Or Comments:
