PERIODONTAL HEALTH AND IMPLANT SURGERY CENTER PRACTICE LIMITED TO PERIODONTAL AND IMPLANT SURGERY Dr. SORIN BOERIU, D.D.S., MSD, PhD., FRCDC. Dip Perio 866 Frederick Street, Unit B Kitchener, ON N2B 2B8 Phone: (519) 578-7830 Fax: (519) 772-2006 Email: info@periohealth.ca REFERRALReferring DentistReferring Office:* Referring Dentist:* Date: MM slash DD slash YYYY Email:* Phone:*Extension Patient InformationPatient Name:* First Last Gender:* Male Female Date of Birth:* MM slash DD slash YYYY Patient’s Home Number:Patient’s Work Number:Extension Patient’s Cell Number:Reason for Referral: General evaluation Specific area Implant placement Specific Area: Crown lengthening: Frenectomy: Mucogingival defect(s): Localized periodontal defect(s): Implant tx: Preferred case completion: Healing collars Final abutments in place Notes:Diagnostic films: Are needed Patient will bring Have been mailed Attached File Attachment: Drop files here or Select files Max. file size: 128 MB, Max. files: 6. Anticipated Restorative Tx: Crown(s) Bridge(s) Removable prosthesis Implant supported Details:
