Referring Doctors — COREY+THEN

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Dental Implants

Cosmetic Surgery

IV/Oral Sedation

Referring Doctors

Patient Resources

Casco Bay Study Club

Dental Implants

Cosmetic Surgery

IV/Oral Sedation

Referring Doctors

Patient Resources

Casco Bay Study Club

Folder: Meet the Team

Folder: Your Smile

Dental Implants

Cosmetic Surgery

Folder: Your Comfort

IV/Oral Sedation

Referring Doctors

Folder: Patient Resources

Casco Bay Study Club

REFERRAL FORM ONLINE SUBMISSION

The Referral Form below is for the use of a referral office only.

Patient Name *

First Name

Last Name

DOB *

Referring Doctor *

Referring For *

Complete Periodontal Evaluation

Isolated Periodontal Exam Area

Crown Lengthening

Soft Tissue Graft/Recession

Implant Evaluation

Other

Comments

Please email all recent radiographs *

PA

BWS

FMX

CLINICAL PHOTOS

PANOREX

CBCT SCAN

NONE

Date of X-rays being sent

Has the patient seen another dental provider in the last 12 months (Specialist)?

Thank you!

254 Western Avenue, Suite 2

South Portland, Maine 04106

P (207)774-5527 | F (207)780-1188

COREY + THEN

PERIODONTICS AND DENTAL IMPLANTS

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Our Office Hours

Monday - Thursday

8:00am - 4:30pm

Friday

8:00am - 3:30pm