Patient Referrals

After completing the following form and attaching the radiographs, please click the submit button to send us the form. Thank you for trusting us with your patients care.

Patient Information

Full Name

Birthdate

Phone with area code

Gender

Male

Female

Primary Reason for Referral

Periodontal Consult

Periodontal Consult Tooth Number

Implant Consult

Implant Consult Tooth Number

Crown Lengthening

Crown Lengthening Tooth Number

Ridge Augmentation

Ridge Augmentation Tooth Number

Gingival Recession (Grafts)

Gingival Recession (Grafts) Tooth Number

Other

Other Tooth Number

Recent Radiographs

FMX

FMX Date Taken

BWX

BWX Date Taken

Panorex

Panorex Date Taken

Digital X-rays

To upload multiple files please compress them into a "zip" file before uploading. Click here for instructions on how to zip your files.

Upload Digital X-rays

Dexis (.dex) is preferred, .jpg or .tif files are fine if .dex is not available.

Conventional X-rays

Please mail conventional x-rays to us. We will scan them and return them to you via mail.

Date of last Root Planing (if applicable)

Date of last cleaning at GDDS

Cleaning is

Perio Maint

Prophy

Interval

Date of last periodic exam at GDDS

Date of next cleaning at GDDS

Date of next periodic exam at GDDS

Referred By Dr. (Full Name)

Date Referred

Dental Insurance

Yes

Dental Insurance Info

1005 N. Evergreen Rd., Suite 102 Spokane Valley, Washington • 99216 • USA • +1 509-927-3272 • email@drnygaard.com