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Referring Doctors
Form to fill out
EN Referring Doctors
Date
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Contact the patient
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Daytime Phone Number
Referring Professional
Prothèse sur implants planifiée
Number of implants
1
2
3
4
5 or 12
Attachements
Locator
Ball
Rider
Removable
RP4
RP5
Fixed
FP3
3PF
PF3
PPP
Remarks
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Referred Patient
Birth date
Evening Phone Number
Reason for consultation
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Scan
Lower jaw
Upper jaw
Radiological guide
Simplant evaluation
Implant
Sinus lift elevation
Bone graft
Soft tissue graft (Alloderm, Gingival, Connective)
Hyperplastic tissues removal
Surgical extraction
Dental crown-lengthening
Position
A
B
C
D
E