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Roy E. Mintzer, DDS
Board Certified Specialist
Periodontics, Implant Placement & Service
Call: (805) 682-5600

Online Referral Form

Roy E. Mintzer, D.D.S.

Periodontics | Dental Implants | Microsurgery

Alamar Dental Center, Santa Barbara

Diplomate, American Board of Periodontology

Referred by:

Date:
Patient Name: Phone #:


My patient requires a

  Complete Examination                  Limited Examination 



TEETH or IMPLANTS to be examined:

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For:

 Periodontal Disease

 Extraction(s):

 Implants

 Esthetics & Smile Evaluation

 Peri-Implantitis

 Frenectomy/Fiberotomy

 Crown Lengthening

 Second Opinion

 Gingival Recession

  Alternating Maintenance Recalls

 Other (Ridge/Bone Augmentation or Modification, etc. -  please describe below)

 


I plan on the following treatment (include implant platform preference):


  Please review the above restorative treatment recommendations

 

Recent X-rays available? Yes No (please take xrays if necessary)
Recent Scaling & Root Planing? Yes No (if applicable)


Comments:

 Please contact me:
 Preferred Maintenance (if applicable):
       Before Consultation       Referring Office         
       After Consultation       Periodontal Office  
       After Treatment       Alternate Recalls        
        No Preference             



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