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Etikala Periodontics
Tel: (206)365-5880
Referral forms
Patient's name
Phone
Email
Birthday
Month
Month
Day
Year
Referring Doctor's name
Pre-Med?
Yes
No
Reason for referral
Comprehensive evaluation for periodontal disease (Need FMXR's within 3 years and BWXR's within 1 year).
Limited SRPs/Osseous surgery (Need periapicals of the area within 1 year).
Recession/grafting
Implants/ bone grafting
Peri-implantitis
Sub gingival restorations
Crown lengthening
Exploratory surgery for root resorption/fractures/caries
Oral Pathology
Other
Comments
X-rays being emailed to info@etikalaperioimplants.com
Yes
No. Take them at your office.
Submit
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