23731 El Toro Road, Suite D,

Lake Forest, CA 92630

(949) 581-8108

info@alifetimedental.com

www.alifetimedental.com

Referrals Form

Referring dentist details

Dentist name
Date
Phone
Email

Patient details

Last Name:
Middle Name:
First Name:
DOB
Phone
Email

*Referral Type:  

Orthodontic Referral Form

Dr. M. Azadeh Afzali D.D.S.
Pon-Surgical Orthodontics
TMJ & Sleep Disordered Breathing
Pastbraces & Clear Correct

Scan to see case studies:

Reason for Referral:

General Orthodontic Evaluation
Early Interceptive Treatment
Fastbraces Consultation
Invisalign Consultation
Orthognathic Surgery Evaluation
Pre-prosthetic / Pre-implant Treatment
TMJ Disorder Evaluation
Sleep Disorder Evaluation

Clinical findings:

Airway/ breathing concerns
Space maintenance
Class II
Open bite
Class III
Crossbite / functional shift
Crowding
Spacing
Missing Teeth
Impacted teeth
Growth/ skeletal imbalance
Overbite
Overjet
Speech concerns

Comments

Please send x-rays and images to: info@alifetimedental.com

Periodontist Referral Form

Dr. Pedram Fakheri, D.M.D.
Periodontist & Implant Surgeon


Reason for Referral:

Comprehensive Perio Exam
DentalImplants
Surgery/Other
Perio Exam Gingival
Esthetic Gingival Recontouring Crown
Exposure
Recession/Grafting
Extraction
Impacted Tooth
Endo/Periapical
Lengthening, Tooth #

Affected Teeth:

Right Side

Upper

Left Side

Lower


Comments

Please send x-rays and images to: info@alifetimedental.com



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