Referral Form

Dr. Logesh Swayamprakasam DDS, MS, MPH

Periodontal Referral

8105 Edgewater Dr. Suite 1 Oakland, CA 94621

Date:

Office:

Patients Name:

Phone Number:

Insurance:

Referring Doctor:

DOB:

Insurance ID#

Radiographs – CT Scan – MRI:

Included

Patient will bring

Please Take

Return Original

Medical/Dental History

Previous Perio Therapy

SRPs

Surgery

Medical Condition

Other Cautions

Call us before seeing the patient Call us after seeing the patient

Send us report by:

Mail

Other: