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Patient Information

Patient Name *

First

Last

Patient Birth Date

Referring DDS *

Teeth Involved

Adult Upper

• 19
• 18
• 17
• 16
• 15
• 14
• 13
• 12
• 11
• 21
• 22
• 23
• 24
• 25
• 26
• 27
• 28
• 29

Adult Lower

• 49
• 48
• 47
• 46
• 45
• 44
• 43
• 42
• 41
• 31
• 32
• 33
• 34
• 35
• 36
• 37
• 38
• 39

Child Upper

• 55
• 54
• 53
• 52
• 51
• 61
• 62
• 63
• 64
• 65

Child Lower

• 85
• 84
• 83
• 82
• 81
• 71
• 72
• 73
• 74
• 75

Radiographs

Radiographs

• Take as needed
• Sent with patient
• Attached
• Emailed
• Mailed

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Date taken

Additional comments on radiographs

Specialties

Specialist

• Dr. Hesam Abbas-Tehrani DDS, MSc Perio (Periodontal)
• Dr. Ryan Margel DMD, MS, FRCD(C) (Endodontic)
• Dr. Mauricio Berco DDS, DMSc, FRCD(C) (Orthodontic)
• Dr. Ihab Kodsi HONBSC, DDS, FRCD(C) (Oral & Maxillofacial)
• Dr. Jonathan Mahn DDS (Implants & Extractions)
• Smile City DentAsleep
• Cone Beam CT

Dr. Hesam Abbas-Tehrani DDS, MSc Perio *

• Sleep dentistry required
• Generalized periodontal evaluation and treatment
• Special concerns
• Guided tissue regeneration
• Surgical crown lengthening
• Implant consultation
• Soft tissue graft
• Aesthetic gingival recontouring
• Ridge augmentation
• Other

Other *

Dr. Ryan Margel DMD, MS, FRCD(C) *

• Sleep dentistry required
• Consult for possible endodontic treatment
• Consult and endodontic therapy (Same day)
• Consult of a previously endodontically treated tooth
• Prophylactic endodontic therapy (crown/bridge planned)
• Post space requried
• CBCT required
• Other

Other *

Dr. Mauricio Berco DDS, DMSc, FRCD(C) *

• Consult for possible orthodontic treatment
• Adult and child comprehensive orthodontic treatment
• Early interceptive treatment for children
• Adult Multidisciplinary treatment
• Other

Other *

Dr. Ihab Kodsi HONBSC, DDS, FRCD(C) *

• Extractions
• Complex medical history
• Implants
• Other

Extractions *

Complex medical history *

Other *

Dr. Jonathan Mahn DDS *

• Implants
• Extractions
• Other

Other *

Smile City DentAsleep *

• Nitrous Oxide
• Sleep dentistry
• General anaesthetic
• Other

Other: *

Cone Beam CT *

• Sextant
• One arch (Maxillary)
• One arch (Mandibular)
• Two archs
• Other

Other *

Remarks/Reason for referral/Diagnosis

Remarks/Reason for referral/Diagnosis

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