San Francisco Reconstructive Periodontics Doctor Referral Form

450 Sutter Street, Suite 1619
San Francisco, CA 94108
(415) 392-1265

Hamed H. Javadi, DDS, FRCD (C)
Greg Meyers, DDS, MSD

Introducing

Patient Phone

Referring Doctor

Doctor Email

Date

REASON FOR REFERRAL:

Complete Periodontal Evaluation

Specific Area

Gingival Recession

Dental Implant

I-CAT Imaging

Other

RECENT FULL MOUTH RADIOGRAPHS:

Upload X-Ray Files

Unavailable, please take new radiographs

Accompanying patient

Emailed to info@sfreconstructiveperiodontics.com

Mailed to your office

Date mailed/emailed

PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE TO DATE:

Plaque control instruction

Prophylaxis and gross scaling

Root planing

Date of service

Periodontal maintenance therapy

every

months for

years

HAVE YOU ADVISED THE PATIENT OF THE POSSIBILITY OF ANY TEETH EXTRACTIONS?:

If yes, which teeth?

PLEASE OUTLINE ANY RESTORATIVE PLANS YOU HAVE FOR TREATING THIS CASE AT THIS TIME:

Comments

Appointment on

Time

Patient Validation