information for doctors
Office Hours:
Portsmouth Office
Open Mondays, Tuesdays and Fridays
8:00am-5:00pm
603-436-8222

Somersworth Office
Open Thursdays
8:00am-5:00pm
603-436-8222

Referral form

Please use our form below to send referrals to our office, thank you!

PATIENT INFORMATION:
* = required field

Today's Date:*

Patient's First Name:*

Patient's Last Name:*

Patient's Telephone:*

Patient's DOB:*

REFERRING DOCTOR INFORMATION:

Referred By:*

Telephone:*

Email:*

Comments:

Evaluation & Consultation
Pathology
Extraction
Implant Consultation
Radiographs being mailed
Radiographs given to patient
Radiographs attached (see below)
No X-Rays


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Please mark any teeth to be evaluated for implants:

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Attach X-ray image(s) by using the SELECT FILES button. Note: if the image you are trying to upload is larger than 1 megabyte please contact Dr. Clarizio's office directly to make arrangements for file transfer.

LOCATION
Edentulous Maxilla Mandible

IMMEDIATE LOAD
Screw in Temp Place abut & return to you for cemented temp

PROVISIONALIZATION:
Removable Flipper Invisible Retainer Fixed

SURGICAL TEMPLATE:
Not Necessary Will Be Provided
When will it be ready: (if applicable)

BONE GRAFTING
Socket Restoration/Maintenance
Ridge Augmentation Width Height Both
Sinus Augmentation

DISTRACTION OSTEOGENSIS:
Width Height Both

SOFT TISSUE ENHANCEMENT:
Width Height Both

BIOPSY:
Yes