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#27 – Fills out referral slips

Fills out referral slips to Periodontist

Fill out referrals to physicians regarding blood pressure or general health problems

Fills out referral slips to Orthodontist

To Periodontist

This sheet should be filled out in detail. Next, the secretary will schedule consult with Dr. Describe the problem on referral slip. Save the slip in the client’s chart for the General Dentist’s signature while she/he reviews the chart. Keep a few of these referral slips at your area so you can fill out quickly and conveniently. If any questions, medical problems, a medical clearance will be sent to their physician. The Periodontist will evaluate before an appointment is made.

  • Systemic illnesses: diabetes, AIDS, chemo therapy
  • Child with bone loss
  • Potential extractions if teeth/gums don’t respond
  • Periodontitis not responding to conservative treatment
  • Severe recession
  • Frenum pull causing recession
  • Lack of attached gingival
  • Crown lengthening

Make sure the perio charting and other hygiene documentation is complete and current x-rays are in the computer. The referral slips are located _________.

Physician referral slips

Medical consults for blood pressure, other health problems, or clearance for dental procedures. These sheets don’t need to be filled out immediately, but should be filled out that day and placed on the general dentist’s desk with the chart so it can be signed. Keep five to ten copies at your area so they can be filled out quickly and conveniently; also located ___________. Keep a copy in the patient’s chart.

To Orthodontist

Write down your general dentist’s comments on the treatment sheet. The orthodontist will be given our chart when the client visits them.

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Hygienist team leader           Date