Dentist - Implant Dentist - Cosmetic Dentist

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(619) 397-4111
(619) 397-4114

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"Our most important assets are ethics, care and responsability..."

Lost a tooth?

We help you to regain your smile, comfort, eating and confidence. Our success rate of dental implants is reliable and predictable.

Thank you for visiting our web site. It's our goal to create a lasting and mutually beneficial relationship with our referring doctors. To help facilitate the referral relationship, we have installed a convenient referral form that can be filled out and sent along with any digital x-rays.

Referral form

To begin with our referral program, fill out the following form. If you have any questions, please visit our contact page.

Patient Name

Referring Doctor

Doctor's e-mail

Date

Introducing

My Patient Requires
A Dental Implant Examination
A Prosthodontic Examination Other

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
RIGHT																	LEFT
	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17

I noted the following problems:
Periodontal Pockets	Bone Loss
Esthetic	Psicological
Occlusal	Other:

This Patient Is:
New To My Practice
A Patient In My Practice For

Periodontal Maintanence Has Been:
Regular	Sporadic

The Following Resorative/Prosthodontic Dentistry is anticipated:

Recent FMX
Is Available and Being Sent
Is Unavailable - Please Take Films In Your Office and Send Us A Copy

Comments:

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Estrella Dental Clinic
2452 FENTON STREET, SUITE 100, BUILDING C.
EASTLAKE, CA.
info@estrelladental.com

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