Nagatomo Implants & Periodontics

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REFERRING DOCTORS

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Patient's Name

Referring Doctor

Patient to call for appointment

Patient's Phone #

Office Phone #

Please contact patient for appointment

Exam Type (If there is no indication, we would like to offer comprehensive exam):

Comprehensive Periodontal Exam

Limited Exam

Periodontal Therapy:

Tooth #

Scaling/Root Planing

Crown Lengthening

Extraction with Ridge Preservation

Ridge/Sinus Preservation

Gum Recession/Root Coverage

Ortho Involved (Pre-Ortho, TAD, PAOO)

Pocket Reduction

Gingivectomy

Root Amputation

Soft Tissue Augmentation

Frenectomy/Fiberotomy

Other

Implant Therapy:

Implant(s) Tooth #

Full Max

Full Mand

Implant Brand Request:

Straumann

Astra

Nobel

Other

Type of Restoration:

Fixed Prosthetics

Removable Prosthetics

Comments:

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