Get the free DETAILED PERIODONTAL REFERRAL FORM - Dr. Murray Arlin

DETAILED PERIODONTAL REFERRAL FORM 1436 Royal York Road, Suite 209, Toronto, Ontario, M9P 3A9 Tel: (416) 243-5215 Fax: (416) 243-0655 Patient Name: Date: Patient Telephone #: Referred by Dr. Date

How to fill out detailed periodontal referral form

How to fill out a detailed periodontal referral form:

1. Begin by entering the patient's personal information, including their name, date of birth, and contact information. This is essential for identification purposes.
2. Provide a brief summary of the patient's dental history, including any previous treatment they have undergone for periodontal issues. Include the reason for the referral and any specific concerns or symptoms the patient is experiencing.
3. Indicate the referring dentist or dental professional's information, including their name, dental practice, contact details, and any applicable professional credentials. This allows for seamless communication between the referring dentist and the periodontist.
4. Document the referring dentist's findings and any relevant diagnostic tests, such as X-rays or periodontal charting. This information helps the periodontist understand the current condition of the patient's gums and teeth.
5. Specify any medications the patient is currently taking, as certain drugs may impact periodontal treatment or require adjustments to the treatment plan.
6. Provide details on the periodontal treatment already performed, such as previous scalings, root planing, or surgical interventions. This information gives the periodontist insight into the patient's previous response to treatment.
7. Include any relevant medical history, as certain conditions or medications can influence the success and safety of periodontal treatment. Information on allergies, cardiovascular issues, pregnancy, or immune system disorders may be important for the periodontist to consider.
8. Describe the patient's oral hygiene practices, including their daily routine and any challenges they may face in maintaining good oral health. This allows the periodontist to provide tailored recommendations and treatment plans.

Who needs a detailed periodontal referral form?

1. Dentists: General dentists who identify periodontal issues or lack the expertise to carry out specialized periodontal treatment may refer their patients to a periodontist.
2. Dental hygienists: If a dental hygienist suspects advanced periodontal disease or any concerning oral health condition that may require specialized treatment, they may refer the patient to a periodontist for further evaluation and care.
3. Patients with advanced periodontal disease: Individuals experiencing severe gum disease, persistent gum inflammation, gum recession, or dental implant complications may benefit from a detailed periodontal referral form to receive specialized treatment from a periodontist.

For pdfFiller’s FAQs

What is detailed periodontal referral form?

The detailed periodontal referral form is a document used to provide information about a patient's periodontal health and treatment needs when referring them to a periodontist.

Who is required to file detailed periodontal referral form?

Dentists and dental specialists are required to file the detailed periodontal referral form when referring a patient to a periodontist.

How to fill out detailed periodontal referral form?

The detailed periodontal referral form should be completed by providing the patient's personal information, details about their periodontal condition, treatment recommendations, and any relevant medical history.

What is the purpose of detailed periodontal referral form?

The purpose of the detailed periodontal referral form is to ensure that the periodontist has all the necessary information to provide appropriate care and treatment to the patient.

What information must be reported on detailed periodontal referral form?

The detailed periodontal referral form should include the patient's name, contact information, relevant medical history, periodontal diagnosis, treatment recommendations, and any other pertinent details.

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