Patient Referral Sheet

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At Precision Implant Care, we value our relationships with referring dental practices and are proud to partner with you in providing our shared patients with the highest quality dental care. We are happy to help with as little or as much as you need.

Please fill out the referral form below or contact us directly at (718) 376-9600.

Email *

Patient Name: *

Referring Doctor: *

Appointment Date: *

YYYY

Procedure: *

Extractions

All of 4/6

Alveoplasty

Implants

TMJ

Torus Removal

Bone Grafting

Biopsy

Frenectomy

Exposure and Bone

3D Cone Beam

Incision and Draining

Other:

Required

Surgical Template: *

To be provided by restorative dentist

To be fabricated by surgeon

Required

Radiographs: *

Being Mailed/Emailed

Hand carry by patient

Please Take

Required

Notes:

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