Refer A Patient

Patient Referral Form

Metro West Orthodontics & Periodontics offers comprehensive periodontal and dental implant therapy and Orthodontic Therapy.

Patient Information
First Name *Required
Last Name *Required
Parent Name
Date of Birth
Telephone *Required
Email *Required
Does the patient require antibiotics prior to treatment? Yes
Referring Doctor Information
Referrer
Telephone
Referrer Email
Periodontics Consultation
Comprehensive Periodontal Evaluation Yes Lesion Evaluation Yes
Infection Yes Ridge Augmentation Yes
Crown Lengthening Yes Recession/Soft Tissue Grafting Yes
Dental Implant Yes Bone Grafting Yes
Oral Pathology Yes CBCT Scan Evaluation Yes
Others
Orthodontics Consultation
Comprehensive Orthodontic Consultation Yes Problem Focused Orthodontic Consultation Yes
Orthognathic Evaluation Yes TMJ Yes
Cleft Lip & Palate Yes Cosmetic Yes
Others
Further Consultation Explanations
Periodontics Procedures
Extraction (check teeth on form below) Yes Alveoloplasty Yes
Dental Implant Yes Incision & Drainage Yes
Frenectomy Yes Sinus Grafting Yes
Esthetic Crown Lengthening Yes Restorative Crown Lengthening Yes
Pre-Prosthetic Surgery Yes Non-Surgical Periodontal Therapy Yes
Surgical Periodontal Therapy Yes Biopsy Yes
Exposure Yes
Others
Orthodontics Procedures
Pre-Orthodontic Evaluation Yes Expose & Bond Yes
Accelerated Orthodontics Yes Smile Analysis Yes
Others
Further Procedure Explanations
Radiographs/Clinical Photos Submission
Radiographs/Clinical Photos Submission
Last X-Ray Date E.g.) January 2020 X-Ray Type
Patient's Last Cleaning Date E.g.) January 2020
Pending Restorative Treatment
Pending Restorative Treatment Yes
History of Periodontal Disease? Yes History of Jaw Pain? Yes
Surgical Guide
Surgical Guide Yes
Provided by Restorative Dentist Yes Provided by Surgeon Yes
Adult Extractions
Tooth 1 Yes Tooth 2 Yes
Tooth 3 Yes Tooth 4 Yes
Tooth 5 Yes Tooth 6 Yes
Tooth 7 Yes Tooth 8 Yes
Tooth 9 Yes Tooth 10 Yes
Tooth 11 Yes Tooth 12 Yes
Tooth 13 Yes Tooth 14 Yes
Tooth 15 Yes Tooth 12 Yes
Tooth 17 Yes Tooth 18 Yes
Tooth 19 Yes Tooth 20 Yes
Tooth 21 Yes Tooth 22 Yes
Tooth 23 Yes Tooth 24 Yes
Tooth 25 Yes Tooth 26 Yes
Tooth 27 Yes Tooth 28 Yes
Tooth 29 Yes Tooth 30 Yes
Tooth 31 Yes Tooth 32 Yes
Child Extractions
Tooth A Yes Tooth B Yes
Tooth C Yes Tooth D Yes
Tooth E Yes Tooth F Yes
Tooth G Yes Tooth H Yes
Tooth I Yes Tooth J Yes
Tooth K Yes Tooth L Yes
Tooth M Yes Tooth N Yes
Tooth O Yes Tooth P Yes
Tooth Q Yes Tooth R Yes
Tooth S Yes Tooth T Yes
Confirmation (confirm teeth checked above - separate with commas)
Comments

 

12225 W. Giles Road La Vista, NE 68128

Mon 9:00 am - 19:00 pm
Tue 8:00 am - 19:00 pm
Wed 8:00 am - 17:00 pm
Thu 9:00 am - 19:00 pm
Fri-Sun Closed