Periodontal Referral

Dr. Yahya Atassi, Periodontist

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Patient Name * Required

DOB * Required

MM slash DD slash YYYY

Referred By

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Reason for Referral

Implants

Sinus Lift

EXT/Bone Grafts

Biopsies

Crown Lengthening

Laser Regeneration

Ridge Aug.

Gingival Aug.

Incision & Draining

SRP

Gingivectomy

Distal/Mesial Wedge

Impacted Tooth Exposure

Site Prep/GBR

Peri Implantitis

Gingival Aug.

Frenectomy/Vestibuloplasty

Osseous Surgery / Pocket Reduction Surgery

Please list teeth/areas of concern:

Comments

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