Dear Doctor __________________________:
Our former patient, ______________________________________________________, has requested that we review our records and x-rays, and forward them to your office. I have reviewed the records and have made notes which may be of assistance.
____Copies of latest (__________BW's) ( __________FMX) (__________Panorex) x-rays sent.
____Nothing of consequence noted in chart.
____Last cleaning & exam was on __________________________.
____Recall frequency of ___3 months ___4 months ___6 months ___12 months has been recommended.
____Periodontal problems have been noted in these areas: _________________________________________________________
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____Notations on oral hygiene: _______________________________________________________________________________
____Consultation with Periodontist has been: ___Recommended ___Completed (Dr. ___________________________).
____Periodontal surgery was: ___Performed ___Recommended (Dr. ___________________________).
____Pulp caps or deep restorations noted on teeth #__________________________.
____Endodontic therapy has been recommended on teeth #_________________________________.
____Consultation with Orthodontist has been: ___Recommended ___Completed (Dr. _________________________).
____Extractions were recommended for teeth #_______________________________________.
____Restorative services have been recommended but not completed on teeth # _______________________________________.
____Crowns were recommended for teeth #_______________________________________________.
____Cast restorations have been recemented on teeth #______________________________.
____Implants have been recommended to replace teeth #_____________________________.
____Fixed bridges have been recommended to replace teeth #______________________________.
____Removable partial denture(s) have been recommended. ____Maxillary ____Mandibular
____New full denture(s) have been advised. ____Maxillary ____Mandibular
____Reline(s) have been advised. ____Maxillary ____Mandibular
____Other concerns: _______________________________________________________________________________________
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____Please call me so we can discuss this case further.
Sincerely,
