Patient's full name

First Name

Last Name

Patient's cell phone number

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Patient is being referred for the following:

periodontal evaluation

gingival grafting (gum graft, gum recession)

implant evaluation

immediate anterior (front) implant placement and temporization (S.M.I.L.E. technique)

crown lengthening

gingival (gum) contouring

ridge or sinus augmentation

periodontal defect bone grafting

pre-prosthetic surgery

3D (cone beam) imaging only

other

Radiographs

📄 Mailed

✉️ Emailed

⚠️ Dr. Edmunds to take needed radiographs