Hamed H. Javadi, DDS, FRCD (C)
Introducing
Patient Phone
Referring Doctor
Doctor Email
Date
REASON FOR REFERRAL:
Complete Periodontal Evaluation
Specific Area
Gingival Recession
Dental Implant
I-CAT Imaging
Other
RECENT FULL MOUTH RADIOGRAPHS:
Unavailable, please take new radiographs
Accompanying patient
Emailed to x-rays@drjavadi.net
Mailed to your office
Date mailed/emailed
PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE TO DATE:
Plaque control instruction
Prophylaxis and gross scaling
Root planing
Date of service
Periodontal maintenance therapy
every
months for
years
HAVE YOU ADVISED THE PATIENT OF THE POSSIBILITY OF ANY TEETH EXTRACTIONS?:
If yes, which teeth?
PLEASE OUTLINE ANY RESTORATIVE PLANS YOU HAVE FOR TREATING THIS CASE AT THIS TIME:
Comments
Appointment on
Time
1615 Hill Road, Suite F
Novato, California 94947
(415) 892-4637
666 Third Street, Suite 28
San Rafael, California 94901
(415) 454-1064
Patient Validation:
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