Referring Clinician

Name: ........................................................................................................................PH: ..........................................

Practice: ....................................... Eml: ...................................................................................................................

Patient Details

Patient Name: .......................................................................................................DOB: .....................................

Patient Ph: ................................... Patient Eml: ..................................................................................................

Treatment Required

Periodontal Therapy Periodontal Surgery Implant Dentistry

|Periodontal examination and/or treatment

|Recession or mucogingival lesion | Implant placement

|Generalised Periodontitis | Soft tissue augmentation |Bone augmentation/ grafting/ sinus lifting

| Localised Periodontitis |Root coverage |Peri-implantitis

|Crown lengthening Implant Type:

|Access surgery

|Muco Gingival surgery

... Straumann

... Dentsply/Astra

... Neoss

... Southern

... Other.............................

Position/s ...................................................................................................................................................................

Other ...........................................................................................................................................................................

P R O A C T I V E P E R I O Per iodont ics & Implant Dent i s t r y

Dr Christopher Barker Per iodontist

Patient to obtain and bring

|OPG |PA |CONE BEAM / CT

Patient history / Comments / Other Resources

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RIGHT

MANDIBULAR ARCH

MAXILLARY ARCH

SUNSHINE COAST

Proactive Perio Suite 18, 5 Innovation Parkway Birtinya QLD 4575

(07) 5301 9342

BRISBANE

Proactive Perio 132 Kedron Brook Road Wilston Qld 4051

(07) 3054 4326

C l i c k h e r e t o b o o k y o u r P a t i e n t ' s A p p o i n t m e n t o n l i n e n o w !

Nicklin Way

Sportsmans Pde

Kawana Waters High School

Kawana Way

Innovation Pky

PROACTIVE PERIO

Lake Kawana

Metier Lnky

Ma

in D

rive

Why have you been referred to Proactive Perio?

Proactive Perio is a specialist Periodontics practice dedicated to helping patients proactively repair and maintain their oral health. In partnership with your general dentist we will provide thorough care in all aspects of Periodontics. Our focus is on specialist periodontal therapy, periodontal surgery and implant dentistry.

Please visit our website www.proactiveperio.com to learn more about Proactive Perio and how we can help you.

Please arrive 15 minutes prior to your scheduled appointment time for administrative purposes. We look forward to seeing you!

PRACTICE LOCATIONS

The friendly staff at the surgery will be able to make appointments with Dr Barker. Just ask!

Main Ave

Stain St

Olney St

Wilston Village

Kedron Brook Rd

PROACTIVE PERIO