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919-841-1720

Oral Maxillofacial Surgeons

Kevin Neshat, DDS, MD
Jorge Perez, DMD
William Benzing, DMD
Amandip Kamoh, DDS
Anthony Immediata, DMD
Dr. Samuel Addison, DDS, M
Alexandra Petraszko, DDS, MD
Bill Konicki, DMD, MD
John Crestetto, DDS, MD
Ken Barringer, DDS

Periodontists

Nathalie Rivero DMD, MS
Justin Tomack DMD, MMSc

Referral

Referring for:

No Preference

Oral Surgery

Periodontics

presenting patient

date

referring dr. (first & last name)

referring dr. email

referring dr. phone

patient phone

patient Email

d.o.b

parent/guardian (if under 18)

dental insurance company name

left

permanent

right

Left Permanent Right

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32

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left

PRIMARY

right

Left Permanent Right

a

b

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d

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g

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Treatment

Wisdom Teeth Removal

Dental Implant(s)

Pathology

Extractions

Socket Preservation

Alveoloplasty

Bone Grafting

Expose & Bond

CT Scan

Complete Exam

Ridge Augmentation

Laser Treatment

Scaling & Root Planing

Crown Lengthening

Soft Tissue Graft

Perio Limited Exam

Pocket Reduction

LANAP (Laser Assisted New Attachment Procedure)

Treatment

Wisdom Teeth Removal

Dental Implant(s)

Periodontal Evaluation – Limited Exam

Extractions

Socket Preservation

Periodontal Evaluation – Complete Exam

Expose & Bond

Ridge/Sinus Augmentation

Laser Therapy (LANAP/LAPIP)

Pathology

Full Arch Rehabilitation

Pocket Reduction

Alveoloplasty

CT Scan

Scaling & Root Planing

Soft Tissue Graft

Crown Lengthening

REMARKS OR SPECIAL INSTRUCTIONS

Details

NU Image to appoint

Patient will contact

Referring dentist to schedule appointment

Appointment (Date & time)

Radiographs

Emailed

Given to Patient

Not Taken

Date Xray Taken

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