Refer an Implant Patient to Dr. Fioritto Cleveland Implant Institute

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PATIENT REFERRALS

Complete the online referral form below
OR
download and fax the PDF form

Patient Information
Patient Name*
First Last
Patient Phone Number*
Referral Reason
Referred For
- Single tooth replacement
- Multi-tooth replacement
- Full Arch Implant Restoration
- Ridge augmentation procedure(s)
- Sinus elevation/grafting procedure(s)
- Stabilization of conventional denture
Single tooth replacement – tooth number(s)
Single Tooth Replacement - Immediate Loading
- And assess for immediate loading with transitional attachment & crown
Multi-tooth replacement – tooth number(s)
Multi-tooth Replacement - Immediate Loading
- And assess for immediate loading with transitional attachments & crowns or bridge
Full Arch Implant Restoration - Immediate Loading
- And assess for immediate loading with transitional prosthesis
Stabilization of conventional denture - Immediate Loading
- Assess for immediate placement/loading
Comments
Radiographs Included
- Panorex
- Periapicals
- CBCT
Radiograph Files
Max. file size: 12 MB.
Referred By Dentist
Referred by Dr.
First Last
Doctor Phone Number
Referral & Follow Up Details
- Please refer back to my office for the completion of the final prosthetic(s) on the implant(s)
- Please complete the final prosthetic(s) on the implant(s)
- Please call about this case following consultation
Name
This field is for validation purposes and should be left unchanged.

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Office Hours & Locations
Just For Dentists
Educational Videos

Mentor Office
6303 Center St
Mentor, OH 44060-2467

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8245 Auburn Road
Concord, OH 44077

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