809 Sylvan Ave., Suite 300 • Modesto, CA 95350
(209) 572-6008 Fax: (209) 572-6009
www.centralvalleyperio.com
IMPLANT REFERRAL
Evaluation
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SELECT TEETH TO BE EXTRACTED:
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IMPLANT SYSTEM:
Periodontal or mucogingival considerations?
 YES
 NO
Would you like a telephone call during the patient's appointment?
 YES
 NO
TENTATIVE RESTORATIVE PLANS:
 Single Unit Crown
 Fixed Bridge
 Over-denture
Radiographs
Enclosed please find all radiographs available from my office.
I have no radiographs. Please take what you will need.
Our office will email radiographs to xray@centralvalleyperio.com
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