Demographic Information

Patient Information

Full Name *

Date of Birth *

Parent/Guardian

Contact Phone Number *

Contact Email Address *

Does the patient require antibiotics prior to dental treatment?

Yes

No

Please call patient

Yes

No

Referring Information

Referring Doctor Information

Practice Name *

Referred By *

Email Address *

Phone Number *

Type of Treatment Needed

Choose Treatment Needed

Sedation
Dental Extractions
Wisdom Teeth Removal
Dental Implants
Bone Grafting
Corrective Jaw Surgery
Trauma
Infections
Pathology
Pediatric Patients
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Procedures

Extractions (see below)

Yes

No

Alveoloplasty

Yes

No

Biopsy

Yes

No

Incision & Drainage

Yes

No

Lesion Evaluation

Yes

No

Infection

Yes

No

Expose & Bond

Yes

No

Frenectomy

Yes

No

Apicoectomy

Yes

No

Other

Yes

No

Consultations

TMJ

Yes

No

Implants

Yes

No

Immediate

Delayed

Orthognathic Evaluation

Yes

No

Pre-Prosthetic

Yes

No

Bone Grafting

Yes

No

Other

Yes

No

Implants

Implants

Please select

Dentsply
Implant Direct
Implant Innovations
ITI
Lifecore
TMI
Branemark
Other
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Surgical Template

Please select

Provided by Periodontist
Provided by Restorative Dentist
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Extraction Information

Area's of Concern

Permanent Upper Teeth 1 to 16

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Permanent Lower Teeth 17 to 32

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

Primary Upper A to J

A

B

C

D

E

F

G

H

I

J

Primary Upper k to t

T

S

R

Q

P

O

N

M

L

K

Verify Teeth for Extraction

Radiographs or Clinical Photos

Radiographs or Clinical Photos

Upload Files

X-Rays, Documents, Images, Radiographs

Case Notes

Case Notes

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