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Marco A. Chiarot
DDS, MD, MSc, FRCD(C)
Joel E. Powell
DDS, MD, MSc, FRCD(C)
Archie Morrison
DDS, MSc, FRCD(C)
Jeanette Johnson
BSc, DDS, FRCD(C)
Lisa Johnson
HBSc, DDS, MSC, FRCD(C)
Date: Monday, November 11th, 2024
IMPLANT REFERRAL
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
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
Implants
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
Pontics
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
8
7
6
5
4
3
2
1
1
2
3
4
5
6
7
8
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 patient a smoker?
yes
no
Does patient 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 patient?
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