Demographic Information

Patient Information

Name

Date Of Birth

Parent / Guardian

Contact Telephone

Contact Email Address

Does The Patient Require Antibiotics Prior To Dental Treatment?

Yes

No

Please Call Patient

Yes

No

Treatment

Referring Office Information

Name of Practice: *

Name Of Referring Provider: *

Phone Number: *

Email Address: *

Preferred Provider

Please Specify Which Provider You Would Like To Refer To:

No Preference

Dr. Aadil Shamji, DMD General Dentist

Dr. Sergio J. Weinberger DDS Cert.Pedo, F.R.C.D.C, M.CI.Dent, F.R.C.D.C (Certified Specialist in Pediatric Dentistry, Certified Specialist in Orthodontics)

Telephone

Email Address

Procedures

Extraction (See Below)

Yes

No

Alveoloplasty

Yes

No

Biopsy

Yes

No

Incision & Drainage

Yes

No

Lesion Evaluation

Yes

No

Exposure

Yes

No

Hard Tissue

Yes

No

Infection

Yes

No

Expose & Bond

Yes

No

Soft Tissue

Yes

No

Frenectomy

Yes

No

Other:

Yes

No

Consultation

Implants

Yes

No

Immediate

Delayed

Pre-Prosthetic

Yes

No

Ridge Augmentation

Yes

No

Oral / Facial Lesion

Yes

No

Bone Grafting

Yes

No

Other:

Yes

No

Extraction Information

Please Verify Teeth For Extraction

Restoration and Crowns

Please Verify Teeth For Restorations

Pulp Therapy

Please Verify Teeth For Pulp Therapy

Space Maintainers

Space Maintainers

Sedation Preference

Sedation Preference

Nitrous

Moderate

Deep or GA

Radiograph or Clinical Photos

Radiographs / Clinical Photos

Being Mailed

Given to Patient

Please Take

No X-Ray

Attached with This Referral

If X-Rays Are Attached, What Date Were They Taken:

Attach X-Rays

Drop File Here Or

Case Notes

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