Refer a Patient Patient Information * Full Name First Name Last Name Date MM DD YYYY Phone (###) ### #### Email * Preferred Contact Method Phone Text Email Who is your General Dentist? What concerns or symptoms are you experiencing? (e.g. gum recession, loose teeth, implant problems, etc.) Have you ever had periodontal treatment before? Yes No Are you currently seeing a Primary Physician? Yes No Please list medications below (if any): Write NONE if not taking anything, including vitamins. Do you have any of the following conditions? Diabetes High Blood Pressure Heart Disease Osteoporosis Autoimmune disorder History of bisphosphonate use Bleeding disorder Other Thank you!
