Periodontal Referral
www.BeautifulTeeth.com
Andy Lee, D.M.D., DMSc
Anastasiya Petrovska, D.D.S.
Introducing
Phone#
Address
City
State
Zip
Patient's Chief Complaint and Expectations
Evaluation and treatment
Evaluation only
Please send FMX & all current x-rays.
Dates Taken:
Does patient see another DDS, Specialist?
Yes
No
Please List
When treatment is complete, please refer back to office
Yes
No
Appointment Date
Appointment Time
Referred by Dr.
Phone #
5252 Sunrise Blvd., Suite #2, Fair Oaks, CA 95628
Phone: (916) 596-3313 | Fax: (916) 863-6532
Patient Validation:
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