Periodontal Associates

	Howard S. Levinbook, D.M.D.
	Jeffrey D. Goldschmidt, D.M.D.

6 Park Place  New Britain, CT 06052 (860) 224-7751

221 Main St.  Southington, CT 06489 (860) 621-0163

Patient's First Name:
Patient's Last Name:
Patient will call for appt.               Please contact patient for appt.
Patients's Phone:	(Home)  (Work)
Referred By:
Pre-medication required               Patient is new to your practice
Please call us prior to consulting with patient.  Yes    No

REMARKS OR SPECIAL INSTRUCTIONS

PLEASE EVALUATE PATIENT FOR:

Periodontal disease / Bone loss	Dental Implants
Crown lengthening #	Surgical Extraction and socket preservation #
Soft tissue grafting #	Ridge augmentation #
Guided tissue regeneration #	Root coverage #
Periodontal cosmetic surgery
Other:

RADIOGRAPHS:	RESTORATIVE THERAPY:
Date of FMX	Is planned (please comment)
FMX to be sent	Will be planned after periodontal evaluation
Patient has FMX	Is not indicated
Patient has PA of isolated area
Please take PA of isolated area