Referring Doctors

Refer to:
Refer to Dr. Timothy Gifford, DDS — Periodontics & ImplantsRefer to Dr. Fardad T. Tayebaty, DMD — Endodontics

Introducing (patient name)

Date

Patient phone

Email

Referring Dr / Office

Office #

Fax #

Office email

How long has patient been in your care?

Tooth #(s)

Treatment to date

Periodontics services:
Full Perio Exam & TreatmentLimited Perio ExamSoft Tissue Eval / GraftingCrown LengtheningImplant ConsultationBiopsy / Oral Medicine

Endodontics services:
Endodontic Eval / ConsultRoot Canal TherapyRoot Canal RetreatmentApicoectomy / SurgeryCracked Tooth EvaluationTrauma / Emergency

Other
Other (please specify)

X-rays:
Sent with patientEmailedMailedNeeded

Upload X-ray

Notes on case