Date

Information

Referring dentist

Reason for the Visit
Complete evaluationEmergency treatmentBone surgeryGuided tissue regenerationGum graftExtraction and bone graftBone alveolar reconstructionSinus liftDental implantPeri-implantitisCrown lengtheningExposure of impacted toothFrenectomyBiopsyOther (check the box and specify below)

Tooth or Area Number

Appointment
The patient will call for an appointment.Le/la patient(e) appellera pour un rendez-vous

X-ray
Discounts to the patientNo X-ray availableI will upload a zip file now

Comments