Doctor Referral

before we ease your pain

we ease your fears

Referring Doctor


Referring Doctor (required)

Referring Doctor Address


Referring Doctor Phone Number

Referring Doctor Email Address

Patient Information


Patient Name (required)

Area to be Evaluated (required)

Desired Treatment

Is Tooth Removal Required?

YesNo

Anticipated Restoration by Referring Doctor


Number of Screw Retained Crowns

Number of Screw Cemented Crowns

Number of Undecided

Anticipated Restoration by Veranda Dentistry

Number of Screw Retained Crowns

Number of Screw Cemented Crowns

Number of Undecided

Do You Want

Provisional CrownHealing AbutmentCover Screw Only

Note to Referring Office
We, by default, will plan bone level, CBCT guided implant placement of straumann, with healing abutments out of occlusion.

I would like to see the proposed crown/implant placement before the surgical guide is ordered.

YesNo

Any timelines or deadlines?

Do not include sensitive personal, financial, or other confidential information (social security, account number, login, passwords, etc.).