Vista Endodontics & Periodontics - North Raleigh

First Name**
Last Name**
Email*
Phone Number**
First Name**
Last Name**
Email**
Phone Number**
Date of Birth*
Parent/Guardian
Insurance Subscriber ID/Member ID*
Preferred Location*
Type a question
Type a question*
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:
Past Periodontal Therapy

InitialSupportiveSurgical
Date Completed:
Restorative Therapy:
Restorative Therapy

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?)
Medical Considerations

YesNo
Notes
Status of Full Mouth X-rays (within past 2 years)?
Status of Full Mouth X-Rays

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
Type a question
Type a question*

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