A. Cheria O'Neal, DMD, MHS
1225 Johnson Ferry Rd, Suite 760
Marietta, GA 30068
Call 770.971.5375
Patient Referral
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Date:
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Patient Name:
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Patient Phone:
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Referred by Doctor:
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Doctor Phone:
Appointment Date:
Appointment Time:
X-rays:
Patient
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Reason:
Periodontal evaluation
Evaluation extraction/implant
Crown lengthening
Gingival recontouring
Recession
Frenectomy
Soft tissue graft
Other
If ‘Other’, please specify:
Periodontal treatment completed in your office:
Gross debridement
Scaling and rooting planing
Periodontal maintenance
Plaque control instruction
More Information:
Any information which will assist us in understanding and rendering a better service to your patient will be greatly appreciated.
