Referral Forms - SoCal Dental Specialists

Sarat Ummethala – Implant Specialist/Emergencies

Patient Name *

Patient Email *

Referred By

Appointment Date and Time

Reason for ReferralConsultationImplant PlacementExtractionGraft/Ridge AugmentationGBRSinus Graft

Please CallBefore ConsultationAfter ConsultationI will restore the implant. Please contact meI will not restore the implant. Please provide total care related to implants.

Teeth Affected

Dental Chart

Reference the image above.

Additional Comments0 / 180

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Dr. Samah Omar – Pediatric Dentist

Patient Name *

Patient Email *

Referred By

Appointment Date and Time

Reason for ReferralComprehensive CareToothacheTraumaConsultation/Problem FocusedDecaySedation/Anesthesia

RadiographsSent with PatientNone Available

Teeth Affected

Dental Chart

Reference the image above.

Additional Comments0 / 180

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DR. Kit Rungcharassaeng – Orthodontics

Patient Name *

Patient Email *

Referred By

Appointment Date and Time

Reason for ReferralCrowdingOverjetDeep BiteCrossbiteSpacingUnderbiteOpen Bite

Reference the image above.

Additional Comments0 / 180

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Aladdin Alardah, DDS, MS – Implants Specialist

Board Certified Implant Specialist

Patient Name *

Patient Email *

Referred By

Appointment Date and Time

Reason for ReferralConsultationImplant PlacementExtractionGraft/Ridge AugmentationGBRSinus Graft

Please CallBefore ConsultationAfter ConsultationI will restore the implant. Please contact meI will not restore the implant. Please provide total care related to implants.

Teeth Affected

Dental Chart

Reference the image above.

Additional Comments0 / 180

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DR. Rinku Parmar – Endodontist

Patient Name *

Patient Email *

Referred By

Appointment Date and Time

Reason for ReferralConsultation/DiagnosisEndodontic TherapyEmergency Treatment3D CBCT

Restorative ConsiderationsPost Space:YesNoAs NeededOther

Teeth Affected

Dental Chart

Reference the image above.

Additional Comments0 / 180

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Nicholas Caplanis, DDS, MS – Periodontics

Board Certified Periodontist

Patient Name *

Patient Email *

Referred By

Appointment Date and Time

Reason for ReferralPerio ExamImplant PlacementExtractionPocket ReductionRecession/Tissue GraftCrown Lengthening

Communication RequestPlease call me prior to seeing patientPlease call me prior to treatmentPlease just send me the report

Teeth Affected

Dental Chart

Reference the image above.

Additional Comments0 / 180

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Adam Shafik – Orofacial Pain Specialist

Board Certified Orofacial Pain Specialist

Patient Name *

Patient Email *

Referred By

Appointment Date and Time

Reason for ReferralCrowdingTMJ/TMDMyofascial PainTrigeminal Neuralgia/Nerve InjuryAtypical Toothache/facial painJaw Clicking and LockingHeadacheBurning Mouth SyndromeSleep ApneaBruxism/Tooth Grinding

Reference the image above.

Additional Comments0 / 180

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