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Dr. Saga Khan, DDS, MSD 421 W. Prospect Avenue, Mt Prospect, IL 60056 pH: (224) 60 PERIOD Email: contacts epicperiodontics.com www.epicperiodontics.com From Dr. Date: Patients name: Patients Contact

How to fill out perio referral form

How to fill out perio referral form

1. To fill out a perio referral form, follow these steps:
2. Start by writing the patient's personal information such as their name, contact details, and date of birth.
3. Include the referring dentist's information, including their name, contact details, and practice name.
4. Specify the reason for the referral, mentioning the specific periodontal condition or concern that requires specialized care.
5. Provide any relevant medical history, including past dental treatments, surgeries, or known allergies.
6. Describe the periodontal examination findings, noting the severity of the condition, any notable symptoms, or specific areas of concern.
7. Indicate any radiographs or additional diagnostic tests that have been performed and attach copies if required.
8. Include any additional comments or relevant information that may assist the periodontist in understanding the patient's condition or treatment goals.
9. Finally, sign and date the referral form to authenticate the referral.
10. Remember to keep a copy of the referral form for your records and provide the original to the patient for their appointment.

Who needs perio referral form?

1. A perio referral form is needed for patients who require specialized periodontal care. This may include individuals with advanced periodontal disease, gum recession, gum infections, or any other periodontal concerns that cannot be adequately addressed by the referring dentist. The referral form helps in effectively communicating the patient's condition and treatment needs to the periodontist.

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What is perio referral form?

The perio referral form is a document used by dental professionals to refer patients to periodontists for specialized treatment related to gum disease and other periodontal conditions.

Who is required to file perio referral form?

Dentists who identify the need for periodontal treatments for their patients are required to file a perio referral form to refer those patients to a specialist.

How to fill out perio referral form?

To fill out the perio referral form, the referring dentist should provide patient information, details about the patient's dental history, the reason for referral, and any relevant diagnostic findings.

What is the purpose of perio referral form?

The purpose of the perio referral form is to ensure that patients receive appropriate care from a periodontist, promoting better management of periodontal disease and contributing to overall dental health.

What information must be reported on perio referral form?

The perio referral form must report patient demographics, dental insurance details, medical history, symptoms or diagnosis, and specific treatment needs.