Patient Referral Form | Georgian Mall Dental Group

Referring Doctor Information

Name of Referring Doctor*

Referring Doctor Phone*

Referring Doctor Email*

Date of Referral*

Patient Information

Patient First Name*

Patient Last Name*

Patient Mobile Phone*

Patient Work Phone*

Patient Date of Birth*

Patient Email*

Radiographs*

Included in this submission
Given to Patient
Please Take
Mailed

Pediatrics

Dr. Nilava Ghatak

Comprehensive treatment
Specific treatment
Emergency treatment
Sedation

Periodontics

Select a Doctor

Dr. Adam Ohayon
Dr. Daniel Fortino

Surgery Type

Gingival recession
Crown lengthening
Bone grafting
Sinus augmentation
Other

Oral Surgery

Select a Doctor

Dr. Bohluli

Surgery Type

Extraction
Pathology
Trauma
Other

Extraction Details

Pathology Details

Trauma Details

Other Details

Endodontics

Dr. Ryan Margel

Consultation
Patient has discomfort
Endo initial treatment
Endo retreatment
Apical surgery

Orthodontics

Dr. Eric Smith

Comprehensive treatment
Limited treatment
Checkup

Prosthodontics

Dr. Mohammed Taheri

Full mouth rehabilitation
Consultation and treatment
Implant pre-surgical planning
All-On-Four planning and restoration
Other

Sedation

Please discuss with patient

Cone Beam Computed Tomography

A. TMJ (please check all that apply)

Close
Open
Bite registration

B. Pathologic investigations

Intra-osseous
Soft tissue
Temporomandibular joints

C. Implants

Stent provided
Measurements
Pathology check only

D. Endodontics

Root fracture
Apical pathoses
Perforation
Canal anatomy

X-Ray Upload

Drop files here or

Special Instructions

How did you hear about us?*