Vista Endodontics & Periodontics - North Raleigh

First Name**
Last Name**
Email*
Phone Number**
First Name**
Last Name**
Email**
Phone Number**
Date of Birth*
Parent/Guardian
Preferred Location*
Type a question
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Please evaluate teeth for:
Please evaluate teeth for:*

ExtractionCanine ExposureImplantPeriodontal Disease ExamSinus LiftRidge AugmentationLANAPCrown LengtheningFrenectomySoft Tissue Graft/RecessionPeri-ImplantitisOral PathologyBone GraftingSedation (Nitrous, Oral, IV)Other
Dr. Ronak Bhagat to call patient before appointment?
Type a question

YesNo
Past Periodontal Therapy:
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InitialSupportiveSurgical
Date Completed:
Restorative Therapy:
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Is planned (comment below)Will be planned after periodontal evaluationIs not indicated
Comments
Medical Considerations? (premed/ on Warfarin/Coumadin therapy? Is or has patient taken bisphosphonates?)
Type a question

YesNo
Notes
Status of Full Mouth X-rays (within past 2 years)?
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Please take and send copyX-rays enclosed/emailedPatient X-rays in AscendCopy given to ptNone provided
File Upload

Cancelof
Additional Helpful Information:
Email this form to NREP@vistadp.com or fax to 984.201.1263.

Please call to set up patient’s appointment or we will contact the patient within two business days after receiving this form.
"Please evaluate teeth for" Condition
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