Online Referral | Sunshineperio

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Patient's First and Last Name

Patient's Phone#

Referring Doctor:

Office phone number

Referring Office Email:

Exam Type:

Comprehensive Evaluation

Limited Evaluation

Reason for Referral

Periodontal Pockets

Crown Lengthening

Gingivectomy/Gingival Hyperplasia

Gingival recession/Lack of attached gingiva/Root Sensitivity

Peri-implantitis/Peri-implant mucositis

High Frenum Attachment/Frenum Pull

Red/White Lesions (Biopsy)

Reason for Referral

Extraction (s)

Root Amputation

Dental Implants

Ridge Augmentation

Sinus Lift

Biopsy

All-On-X

Select Quadrant(s)

URQ

LRQ

ULQ

LLQ

Maxillary

Mandibular

Select Tooth/Teeth Numbers:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Select Tooth/Teeth Numbers:

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

Please email all related radiographs, clinical/intra-oral photos, CBCT scan screenshots, notes to consult@sunshineperio.com

Additional Notes/ Restorative Plan:

Thank you and we appreciate your referral. Have a great day.

1799 66th Street North, St. Petersburg, FL- 33710

727-222-3220

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