Refer A Patient

Patient Referral Form

Metro West Orthodontics & Periodontics offers comprehensive periodontal and dental implant therapy and Orthodontic Therapy.

Patient Information
First Name	*Required
Last Name	*Required
Parent Name
Date of Birth
Telephone	*Required
Email	*Required
Does the patient require antibiotics prior to treatment?	Yes
Referring Doctor Information
Referrer
Telephone
Referrer Email
Periodontics Consultation
Comprehensive Periodontal Evaluation	Yes	Lesion Evaluation	Yes
Infection	Yes	Ridge Augmentation	Yes
Crown Lengthening	Yes	Recession/Soft Tissue Grafting	Yes
Dental Implant	Yes	Bone Grafting	Yes
Oral Pathology	Yes	CBCT Scan Evaluation	Yes
Others
Orthodontics Consultation
Comprehensive Orthodontic Consultation	Yes	Problem Focused Orthodontic Consultation	Yes
Orthognathic Evaluation	Yes	TMJ	Yes
Cleft Lip & Palate	Yes	Cosmetic	Yes
Others
Further Consultation Explanations

Periodontics Procedures
Extraction (check teeth on form below)	Yes	Alveoloplasty	Yes
Dental Implant	Yes	Incision & Drainage	Yes
Frenectomy	Yes	Sinus Grafting	Yes
Esthetic Crown Lengthening	Yes	Restorative Crown Lengthening	Yes
Pre-Prosthetic Surgery	Yes	Non-Surgical Periodontal Therapy	Yes
Surgical Periodontal Therapy	Yes	Biopsy	Yes
Exposure	Yes
Others
Orthodontics Procedures
Pre-Orthodontic Evaluation	Yes	Expose & Bond	Yes
Accelerated Orthodontics	Yes	Smile Analysis	Yes
Others
Further Procedure Explanations

Radiographs/Clinical Photos Submission
Radiographs/Clinical Photos Submission
Last X-Ray Date	E.g.) January 2020	X-Ray Type
Patient's Last Cleaning Date	E.g.) January 2020
Pending Restorative Treatment
Pending Restorative Treatment	Yes
History of Periodontal Disease?	Yes	History of Jaw Pain?	Yes
Surgical Guide
Surgical Guide	Yes
Provided by Restorative Dentist	Yes	Provided by Surgeon	Yes
Adult Extractions
Tooth 1	Yes	Tooth 2	Yes
Tooth 3	Yes	Tooth 4	Yes
Tooth 5	Yes	Tooth 6	Yes
Tooth 7	Yes	Tooth 8	Yes
Tooth 9	Yes	Tooth 10	Yes
Tooth 11	Yes	Tooth 12	Yes
Tooth 13	Yes	Tooth 14	Yes
Tooth 15	Yes	Tooth 12	Yes
Tooth 17	Yes	Tooth 18	Yes
Tooth 19	Yes	Tooth 20	Yes
Tooth 21	Yes	Tooth 22	Yes
Tooth 23	Yes	Tooth 24	Yes
Tooth 25	Yes	Tooth 26	Yes
Tooth 27	Yes	Tooth 28	Yes
Tooth 29	Yes	Tooth 30	Yes
Tooth 31	Yes	Tooth 32	Yes
Child Extractions
Tooth A	Yes	Tooth B	Yes
Tooth C	Yes	Tooth D	Yes
Tooth E	Yes	Tooth F	Yes
Tooth G	Yes	Tooth H	Yes
Tooth I	Yes	Tooth J	Yes
Tooth K	Yes	Tooth L	Yes
Tooth M	Yes	Tooth N	Yes
Tooth O	Yes	Tooth P	Yes
Tooth Q	Yes	Tooth R	Yes
Tooth S	Yes	Tooth T	Yes
Confirmation (confirm teeth checked above - separate with commas)
Comments

12225 W. Giles Road La Vista, NE 68128

Mon	9:00 am - 19:00 pm
Tue	8:00 am - 19:00 pm
Wed	8:00 am - 17:00 pm
Thu	9:00 am - 19:00 pm
Fri-Sun	Closed