Referring Dentists Online Referral Form – Linked to Referrals heading
Please enter the following fields to complete the referral. Please contact us by phone
with any questions or to provide additional information.
You can email Dr. Burdine at: drb@drburdine.com, or phone him at 713.688.5200.
Patients Name
Patients Phone Number
Referring Doctor
Doctor's Phone Number
Doctor's Email
Examination Request
Emergency Exam
Implant Evaluation
Ridge augmentation
Sinus graft
Cosmetic considerations
Complete Periodontal Evaluation
Residual pocketing
Gingival recession
Areas needing bone regeneration
Cosmetic root coverage
Cosmetic re-contouring
Occlusal problems
Periodontal prosthetic evaluation
Vertical dimension
Pathologic tooth migration
Crown/root rations for prosthetic support
Crown lengthening
Occlusal plane
Oral Pathology/Biopsy
Area or tooth number of interest _____________ (place a high number of
characters in this field)
Periodontal treatment completed in your office to date: Fill-in here
Plaque control instruction
Root planning
Date of service (type in): 2/8/2016
Local delivery of chemotherapeutics
Prophylaxis and gross scaling
Periodontal maintenance therapy every ___________ months for
__________ years
Have you advised the patient of the possibility of extraction of any teeth?
No
Yes
If yes, which teeth? Fill-in here
Is there any restorative dentistry that needs to be completed?
Describe
Please call BEFORE seeing patient
Please call AFTER seeing patient
Please email details after seeing patient
Current X-Rays
Sent by mail
Sent with patient
Current models:
Yes
No
Patient Background
Requires Antibiotic Prophylaxis
Patient Concerns
Remarks or Special Instructions
Please take