Dear Doctor __________________________:

Our former patient, ______________________________________________________, has requested that we review our records and x-rays, and forward them to your office.  I have reviewed the records and have made notes which may be of assistance.

 

____Copies of latest   (__________BW's)   ( __________FMX)    (__________Panorex)                x-rays sent. 

____Nothing of consequence noted in chart. 

____Last cleaning & exam was on __________________________. 

____Recall frequency of   ___3 months   ___4 months   ___6 months   ___12 months     has been recommended. 

____Periodontal problems have been noted in these areas:  _________________________________________________________ 

      ______________________________________________________________________________________________________ 

      ______________________________________________________________________________________________________ 

____Notations on oral hygiene:  _______________________________________________________________________________ 

____Consultation with Periodontist has been:   ___Recommended   ___Completed  (Dr. ___________________________). 

____Periodontal surgery was:   ___Performed   ___Recommended  (Dr. ___________________________). 

____Pulp caps or deep restorations noted on teeth #__________________________. 

____Endodontic therapy has been recommended on teeth #_________________________________. 

____Consultation with Orthodontist has been:   ___Recommended   ___Completed  (Dr. _________________________). 

____Extractions were recommended for teeth #_______________________________________. 

____Restorative services have been recommended but not completed on teeth # _______________________________________. 

____Crowns were recommended for teeth #_______________________________________________. 

____Cast restorations have been recemented on teeth #______________________________. 

____Implants have been recommended to replace teeth #_____________________________. 

____Fixed bridges have been recommended to replace teeth #______________________________. 

____Removable partial denture(s) have been recommended.    ____Maxillary    ____Mandibular 

____New full denture(s) have been advised.    ____Maxillary    ____Mandibular 

____Reline(s) have been advised.    ____Maxillary    ____Mandibular 

____Other concerns:  _______________________________________________________________________________________ 

      _____________________________________________________________________________________________________ 

____Please call me so we can discuss this case further.

 

Sincerely,

 

Dr. _________