Casey Hein & Associates

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Physician Request for Patient Consult for Examination for Periodontal Disease and Referral Form

Increase direct referral to dental practices of patients by making it easy for physicians, physicians’ assistants, nurses, pharmacists, diabetes educators and other non-dental healthcare providers to screen patients for periodontal disease.

The Physician Request for Patient Consult for Examination for Periodontal Disease & Referral Form lists a number of reasons for concern for the patient, such as “patient has poorly controlled diabetes,” or “patient has chronic kidney disease or is undergoing dialysis”, (among other scientifically founded rationale for referral). It also offers a checklist of evidence-based risk factors and signs and symptoms of periodontal disease to help non-dental providers accurately and efficiently screen patients for periodontal disease. The reverse side of the referral form is a customized message for patients which include important information about periodontal-systemic links to encourage patients to follow through with the referral. A section on the referral form is reserved for dentists and dental hygienists to include their name and contact information to assist patients in contacting their dental offices. 5×8 inch referral forms are packaged in tear off pads in quantities of 25 individual referral forms.

Casey Hein & Associates holds the copyright on the proprietary referral form entitled, Physician Request for Patient Consult for Examination for Periodontal Disease & Referral Form, United States Copyright Office; all rights reserved. Reproduction or use of the Physician Request for Patient Consult for Examination for Periodontal Disease & Referral Form, or any verbiage or images contained on this patient questionnaire, is expressly forbidden without permission of Casey Hein & Associates.

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