Referral Form to Georgia Prosthodontics

Thank you for trusting the care of your patient and teaming up with Us.

Georgia Prosthodontics is a team of experts committed to the higher standard of care. We are dedicated to help patients with complex cases usually involving Advanced Implant, Cosmetic and Reconstructive dentistry. Do not hesitate to contacting us

Call Us or Text Us (770) 381 9333

Referring Doctor

Referring Email address

Office Phone number

First name

Last name

Do you have a preference to who treats your patient?

Patient Information

First name

Last name

Date of birth

Patient's Contact Information

Phone number

Email address

Chief Complaint

Patient's chief Complaint

Dental History

Notes:

The following Diagnostic Aides are available from my office

Full Series of Radiographs

Panoramic Radiograph

CBCT

Photographs

Other

None

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Referral Form to Georgia Prosthodontics

Thank you for trusting the care of your patient and teaming up with Us.

Referring Doctor

Do you have a preference to who treats your patient?

Patient Information

Patient's Contact Information

Chief Complaint

Dental History

Thank you for trusting the care of your patient and teaming up with Us.

Georgia Prosthodontics - Smile Specialists