THE PATIENT IS REFERRED TO

  Dre Marie-Danielle Messier
  Dre Karin Emde
  First available

DATE

PATIENT INFORMATION

REFERRED BY

APPOINTMENT

  Please contact the patient to book an appointment
  The patient will call to book an appointment

RADIOGRAPHS

  No recent radiographs available
  Will be sent separately
  Given to patient

CONSULTATION OBJECT

  Complete periodontal evaluation
  Specific periodontal evaluation
  Acute periodontal infection/Emergency
  Crown lengthening
  Gingival grafts
  Frenectomy
  Implant(s)
  Sinus lift
  Extraction and socket preservation
  Ridge augmentation
  Peri-implantitis
  Other

TOOTH NUMBER

COMMENTS

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