Redwood Periodontics

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Date of Referral
Referring Dentist Name
Referring Dentist Phone
Referring Dentist email
When would you first like us to contact you?
- Before contacting the patient
- After contacting the patient, before moving forward with recommendations
- Only contact me if there are issues or questions
Patient Name
Patient Phone (Primary)
Patient Phone (Secondary)
Patient Email
Comments (optional)
Restorative Therapy
- Is planned
- Is not indicated
- Will be planned after evaluation
Implant Dentistry Needed
- Single implants
- Bridge supported
- Denture retaining
Periodontal Evaluation for:
- Gingivitis
- Periodontitis
- Recession
- Crown Lengthening
- Frenectomy
- Biopsy
- Gingival Contouring
- Other
Soft Tissue Enhancement
- Esthetic gingival countouring
- Tissue reduction for access
- Gingival enhancement
Number of Extractions:
Additional procedures/evaluations recommended:

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