proactive perio dr christopher barker periodontist ... · proactive perio is a specialist...
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Referring Clinician
Name: ........................................................................................................................PH: ..........................................
Practice: ....................................... Eml: ...................................................................................................................
Patient Details
Patient Name: .......................................................................................................DOB: .....................................
Patient Ph: ................................... Patient Eml: ..................................................................................................
Treatment Required
Periodontal Therapy Periodontal Surgery Implant Dentistry
|Periodontal examination and/or treatment
|Recession or mucogingival lesion | Implant placement
|Generalised Periodontitis | Soft tissue augmentation |Bone augmentation/ grafting/ sinus lifting
| Localised Periodontitis |Root coverage |Peri-implantitis
|Crown lengthening Implant Type:
|Access surgery
|Muco Gingival surgery
... Straumann
... Dentsply/Astra
... Neoss
... Southern
... Other.............................
Position/s ...................................................................................................................................................................
Other ...........................................................................................................................................................................
P R O A C T I V E P E R I O Per iodont ics & Implant Dent i s t r y
Dr Christopher Barker Per iodontist
Patient to obtain and bring
|OPG |PA |CONE BEAM / CT
Patient history / Comments / Other Resources
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RIGHT
MANDIBULAR ARCH
MAXILLARY ARCH
SUNSHINE COAST
Proactive Perio Suite 18, 5 Innovation Parkway Birtinya QLD 4575
(07) 5301 9342
BRISBANE
Proactive Perio 132 Kedron Brook Road Wilston Qld 4051
(07) 3054 4326
C l i c k h e r e t o b o o k y o u r P a t i e n t ' s A p p o i n t m e n t o n l i n e n o w !
Nicklin Way
Sportsmans Pde
Kawana Waters High School
Kawana Way
Innovation Pky
PROACTIVE PERIO
Lake Kawana
Metier Lnky
Ma
in D
rive
Why have you been referred to Proactive Perio?
Proactive Perio is a specialist Periodontics practice dedicated to helping patients proactively repair and maintain their oral health. In partnership with your general dentist we will provide thorough care in all aspects of Periodontics. Our focus is on specialist periodontal therapy, periodontal surgery and implant dentistry.
Please visit our website www.proactiveperio.com to learn more about Proactive Perio and how we can help you.
Please arrive 15 minutes prior to your scheduled appointment time for administrative purposes. We look forward to seeing you!
PRACTICE LOCATIONS
The friendly staff at the surgery will be able to make appointments with Dr Barker. Just ask!
Main Ave
Stain St
Olney St
Wilston Village
Kedron Brook Rd
PROACTIVE PERIO