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Katherine Ni, DMD, MS, PC
Periodontics and Dental Implants

Doctor Referral

Patient Name:
Patient Telephone Number:
Patient Email:



Reason for Referral:
Periodontal Evaluation Gingival Recession Crown Lengthening
Frenectomy Implants Other

Radiographs:
Emailed (separate attachment) Take As Needed
Attached Given to Patient

Requires Premedication:
No Yes Reason: Antibiotic Prescribed:

Appointment Info:
Call me before appointment Notify me if patient is not
scheduled by:
Contact patient to schedule appointment Notify me by letter after appointment



Referring Doctor:
Staff Member:
Comments:


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