Northwest Center for Implants & Periodonties

• Dental Implants
• Non-Surgical Options
• For Doctors
• New Patients
• Financial Options
• Testimonials
• Periodontal Procedures

Testimonials

Randy Decker

I had struggled with periodontal disease for about 15 years. I always refused to have surgery on my gums and tried many alternatives. Then I learned about a new technique that could finally relieve me of bleeding gums and more bone loss of my teeth read more...

Karmella Howard

I just wanted to send a short note to thank you and your office for the care given over the last two years. Your staff was very accommodating read more...

Periodontal Referral Form

First Name:
Last Name:
Patient Phone:
Referring Doctor:

Complete Periodontal Evaluation      Early      Moderate      Advanced
REASON FOR REFERRAL	RADIOGRAPHS
Implants	Being Mailed Given to Patient Please Take No X-Ray
Gingival Recession	IMPLANTS
Graft For Root Coverage	Dentsply Implant Innovations ITI Lifecore TMI Branemark Other Restore
Crown Lengthening	SURGICAL TEMPLATE
Guided Tissue Regeneration	Provided by Restorative Dentist Provided by Periodontist
Gingival Contouring For Cosmetics
Ridge Augmentation
Extraction
Other

 

PERIODONTAL TREATMENT COMPLETED IN YOUR OFFICE

Plaque Control Instruction

Prophylaxis and Gross Scaling

Root Planning

Periodontal Maintenance Therapy

 

Have you advised the patient of the possibility of extraction of any teeth? If yes, which tooth numbers?
Tooth #s:
Is there any restorative dentistry that needs to be completed?
COMMENTS
Please include digital radiograph by pressing the browse button and locating the image on your hard drive: