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Patient's first name
*
Patient's last name
*
Email
*
Phone
*
Referred by Dr
Dentist's first name
*
Dentist's last name
*
Email
*
Phone
*
Insert Radiographs if applicable
Radiographs 1
Max. file size: 2 MB.
Radiographs 2
Max. file size: 2 MB.
Radiographs 3
Max. file size: 2 MB.
Radiographs 4
Max. file size: 2 MB.
Radiographs 5
Max. file size: 2 MB.
Reason for consultation
*
Complete periodontal evaluation
Specific periodontal evaluation
Gingival grafts
Implant(s)
Extraction and ridge preservation
Sinus lift
Clinical crown lengthening
Exposure of impacted canines
Peri-implantitis treatment
Frenectomy
Oral pathology
Teeth #
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