MEDICAL REFERRAL LETTER
Date: August 19, 2022
To:
Physician Consult Inc
Subject: Letter of Medical Necessity
To Whom It May Concern / Dear Dr.,
I am referring Jane Doe who is a patient of record in your office for a medical consultation and
consideration for Diabetes Mellitus. She is a white female 55 years old and currently weighs 220 lbs
pounds and is 5’7 inches tall. Her BMI is 34.45. Her in clinic blood sugar level after eating a light
breakfast was 210 mg. During the assessments gathered she presented with heavy gingival
inflammation. The treatment plan recommended is a non-surgical periodontal therapy scaling
procedure. We would like to clear out diabetes or factor it into our treatment plan.
If you have any questions, please feel free to contact me at Villagomezirdh@gmail.com
Looking forward to your reply.
Kind Regards,
Icela Villagomez RDH