Referral Form

Referral Form

MK PERIODONTICS AND IMPLANTS
Minou Karbakhsch, DDS, MSD
Michi Katafuchi, DDS, MSD
Yi-Chen Chiang, DDS, MS
Diplomates of the American Board of Periodontology
www.mkperio.com
1901 South Union Avenue Building B,
Suite 5010 Tacoma, WA 98405,
Phone: (253) 752-6336
Fax: (253) 752-5655
info@mkperio.com
Referring Doctor/Office:
Date:

MonthDayYear
Introducing Patient:
Date of Birth:

MonthDayYear
Patient Email Address:
example@example.com
Patient Phone Number:
Please enter a valid phone number.
Premedication Required:

Check if YES
Recent FMXR available:

Check if YES
Reason for Referral/Areas/Tooth Numbers:
Type of Exam:

Comprehensive ExamLimited ExamPre ProstheticPre Orthodontic
Condition/Treatment:

Initial Periodontal Therapy / Guided BioFilm Therapy (GBT)Recession / Root CoveragePeriodontal Maintenance Therapy and EducationLANAP / Surgical Laser TherapyOsseous Surgery / Pocket ReductionLAPIP / Laser Peri-Implantitis TherapyClinical Crown Lengthening / FunctionalRidge AugmentationAnterior Crown Lengthening / AestheticSinus LiftSurgical ExtractionsBOTOX® Therapy / BruxismAll on “X” Treatment / All-on-4®Oramyofuctional TherapyDental Implant(s)Other
Implant System Choice:
Add Attachments

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HIPAA ACKNOWLEDGEMENT
Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold MK Periodontics & Implants, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.
We are committed to excellence in patient care. Thank you for your confidence and trust.
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