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Referred by Dr.:




May we call the patient:


Daytime Phone:


Reason for referral:

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


 Implant Consultation

Tooth/Teeth #  

 Crown Lengthening

Tooth/Teeth #  



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

Tooth/Teeth #  


Dr. Giardino to take needed x-rays:


Appointment Date:





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


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