Dr. Shakeel Ahmed

11 Ralph Place, Suite #207, Staten Island, NY 10304

718-727-4141

Referral Form

Patient Name:

Patient Name:

Phone No:

Phone No:

Email:

Email:

Referring Doctor Name:

Referring Doctor Name:

Phone No:

Phone No:

Address:

Address:

Reason for Referral

Periodontal Evaluation Only

Bone Graft

Implant

Osseous Surgery

Crown Lengthening

Gingivectomy

Tissue Grafts

Frenectomy

Emergency Evaluation (problem focused)

Other

Tooth #(s)

Tooth #(s)

Quads:

Quads:

Has the patient had previous periodontal therapy?

None

Prophylaxis Only

Antimicrobial Therapy

Scaling and Root Planning

Surgery

Have you advised the patient of the possibility of extraction of any teeth?

Have you advised the patient of the possibility of extraction of any teeth?

Yes No

If yes which teeth?

If yes which teeth?

Does the patient require premedication?

Does the patient require premedication?

Yes No

Antibiotic used:

Antibiotic used:

Radiographs:

Radiographs:

Please take/send copy Patient will bring copy I will send / Please return

Your Restorative Plans

Your Restorative Plans

Comments:

Comments:

Please

Please

Call me before seeing the patient Call me after seeing the patient Alternate recare appointments Do all recare

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Date:

Date:

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