REFERRING DOCTOR
           
 Last Name:*  First Name*    
 Telephone:*  Fax:  Email:
           
 PATIENT INFORMATION
 
 Last Name:*  First Name* Pronouns
 Street Address:  D.O.B.
 City:  Province:  Postal Code:
 Home Phone:  Cell/Work:  Email:*
 
 
 Dental Insurance Plan Holder
  None     ...OR...      SELF      Spouse      Common Law      Guardian
Group/Private
 Name:  Plan/Group #   ID/Cert. #
 Plan Holder:    
 (Last Name)  (First)     DOB
           
 
 CITADEL SURGEONS  (Please indicate preference of surgeon(s) for your patient)
 
First Available     Marco A. Chiarot     Joel E. Powell     Other
 
 Final restorative/prosthetic plan (check all that apply):
Fixed -> Crown FPD All-On- denture (with immediate conversion? yes no)
removable -> Full prosthesis ...OR... partial denture
 Attachment Mechanism: Locators™ / NovaLoc™ Conus™ other:
 
 Provisional Plan:
None    RPD wit ovate pontic    Essex
Immed temp crown ( Lab fab. -shade: ...OR... Chair side - Screw ...OR... Cement)
-> if cannot temporize case: no restoration    Lab fab. Essex    Lab fab. RPD
 Other:
 
 
Implant System(s) Preference:   Lab Preference:
Extractions
     
     
 
Implants
     
     
 
Pontics
     
     
 
 Detailed proposed treatment plan:
 
 Radiographs Included (please do not send BW’s):
Pan    PA (must show apex)   CBCT   none   mailed   emailed
 Date of exposure:  
Medical History or Medications of Note: Is the paitent a smoker? yes no
Does paitent have any parafunction? yes no
If yes, do they have a bite plane or guard? yes no
Is there an existing or previous prosthesis? yes no   Age of prosthesis:
Have fees for provisional and final prostheses been discussed with paitent? yes no
Related to an accident or WCB claim? yes no
        Date of accident: WCB Claim #:
 
Please send all correspondence to:
3480 Joseph Howe Drive, Suite 301 St. Lawrence Place, Halifax, Nova Scotia B3L 4H7
tel 902.442.9720 | fax 902.468.2306 | www.citadelsurgery.ca
Offices also in Dartmouth, Bridgewater and Yarmouth