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Introducing:

 

Referred by Dr.:

 

E-mail:

 

May we call the patient:

   Yes

Daytime Phone:

 
     No

Reason for referral:

   Periodontal Disease Evaluation
(Please send current Perio chart if available)
History of Scaling and Root Planing?
   

Date:  


 Implant Consultation

Tooth/Teeth #  

 Crown Lengthening

Tooth/Teeth #  

   Functional

 Esthetic

 Gingival Recession/Connective Tissue Grafting
(Please send current Perio charting if available)

Tooth/Teeth #  

 Other


Dr. Giardino to take needed x-rays:
 


Comments:
 

Appointment Date:

 

Time:

 
     
       

   
 

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2700 Southeast Blvd. Ste. 210
Spokane, WA 99223
Ph. 509.536.7032
Fax. 509.536.7002


 
 

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