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Referring Doctors
This is to introduce you to my patient*
Patient phone number*
Date*
Referred by*
Reason for your referral*
Complete periodontal evaluation
Limited/localized periodontal evaluation
Gingival recession/mucogingival problem
Crown lengthening
Bone grafting
Dental implant evaluation
Pertinent dental history
Tentative restorative plan
Pertinent dental history
Recent radiographs*
Will be emailed
Not available/please take new radiographs
Patient will bring
Will be mailed
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