Referral Form for Dentists
Barry A. Sogoloff, D.M.D., M.S.
Practice Limited to Periodontics
23250 Chagrin Boulevard
Building Five, Suite 205
Beachwood, Ohio 44122
(216) 292-6787
F: (216) 765-1772
Appointment Information: This time is reserved specifically for you. If by necessity, you must cancel your appointment for surgery, please notify our office at least 48 hours in advance.
Appt. Date: ________________________________ Time: __________________________ AM/PM
Patient’s Name: _____________________________________________________________
Referred By: ________________________________________________________________
Barry A. Sogoloff, D.M.D., M.S.
216-292-6787
I WOULD LIKE YOU TO:
Call me before seeing this patient
Call me after seeing this patient
Notify me by letter after visit
MEDICAL ALERTS:
Allergies
Premedication required. Antibiotic used: ____________________________
Patient desires sedation
PERIODONTAL HISTORY:
Previous root planning. Date of service:_____________________________
Other: ________________________________________________________
REASON FOR REFERRAL:
Periodontal Disease
Biopsy _______________________________________________________
Stomatitis (lichen planus, pemphigoid)
Dental Implants ________________________________________________
Ridge Deficiency
Sinus Pneumatization
Extraction / Socket Graft
Recession # ___________________________________________________
Frenum Labial / Lingual # ________________________________________
Gummy Smile
Preprosthetic – soft tissue augmentation
Restorative Plans: ______________________________________________
RADIOGRAPHS:
I will send Patient will bring Please take Return originals
REMARKS / SPECIAL INSTRUCTIONS: ________________________________________
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