. . Practice: Dentist: Date of referral: Patient Name: DOB: Age: Smoker: YesNo If 'Yes', number per day: Diabetic Yes No Type1 Type2 Well Controlled Not Well Controlled Other medical details: List the Amount of Missing Teeth below: Tissue tone: HealthyInflamed Smile Line LOW (doesn’t show gums on broadest smile)MEDIUM (shows some gum but tops of teeth hidden)HIGH (shows tops of teeth) Oral hygiene: EXCELLENT GOOD POOR VERY POOR Dental Health EXCELLENT MINOR WORK REQUIRED EXTENSIVE WORK REQUIRED Hygiene Support 3 MONTHLY6 MONTHLY12 MONTHLY/ IRREGULARNONE Aesthetic demands: VERY HIGHHIGHMODERATELOW Occlusion (Angles): Class 1 Class 2 div 1 Class 2 div 2 Class 3 Reason for tooth loss: CARIESTRAUMAFRACTUREPERIODONTALENDO Date of tooth loss: Please carry out the following Placement Only Placement and Restoration Only All Necessary Treatment Other comments (including patient’s desires, relevant social history, any deadlines etc): SEND Thank you. We will be in touch shortly.
