Get the free Periodontal Referral Form

This document serves as a referral form for patients to receive periodontal examinations and treatments from Dr. Yi Yang.

How to fill out periodontal referral form

How to fill out periodontal referral form

1. Obtain the periodontal referral form from the dental office or online.
2. Fill in the patient's personal information, including name, contact details, and date of birth.
3. Include the referring dentist's information, such as name, practice name, and contact information.
4. Specify the reason for referral, detailing any specific concerns or conditions.
5. List any previous treatments or procedures the patient has undergone.
6. Document the patient's medical history and any relevant medications.
7. Include any necessary diagnostic records, such as X-rays or periodontal charts.
8. Review the completed form for accuracy and sign it if needed.
9. Submit the referral form to the periodontal office via fax, email, or in person.

Who needs periodontal referral form?

1. Patients experiencing gum disease or periodontal issues.
2. Individuals requiring specialized treatment for advanced periodontal conditions.
3. Patients with a history of dental problems that may warrant periodontal evaluation.
4. Dentists who identify periodontal concerns during routine check-ups and need to refer.

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What is periodontal referral form?

A periodontal referral form is a document used by dentists to refer patients to a specialist in periodontics for periodontal treatment or evaluation.

Who is required to file periodontal referral form?

General dentists or other dental professionals who identify periodontal issues in a patient that require specialized treatment are required to file a periodontal referral form.

How to fill out periodontal referral form?

To fill out a periodontal referral form, the referring dentist should provide the patient's personal information, a detailed description of the periodontal condition, the specific reason for the referral, and any relevant medical history.

What is the purpose of periodontal referral form?

The purpose of the periodontal referral form is to communicate critical patient information to a periodontist, ensuring the patient receives appropriate and timely care for periodontal diseases.

What information must be reported on periodontal referral form?

The periodontal referral form must report the patient's name, contact information, medical history, dental history, specific periodontal findings, and the reason for referral.