How to Refer

Contact Information

Patient Name Referred (required)

Referring Doctor (required)

Patient's Email

Reasons for Referral

• Comprehensive Exam and Treatment
• Biopsy
• Soft Tissue Grafting/Recession
• Periodontitis
• Evaluation for Implants
• Other

Specific Concerns

Diagnostic Films & Models

• X-rays being sent or emailed to info@indyimplants.com
• Study models are available to be picked up
• Patient has films
• There are no current films available
• Mounted models are available
• X-rays are available to be picked up
• Dental Implant Restorative Plan:
• Single implant-supported crowns(s), sites(s):
• Multiple unit restoration from to
• Fully edentulous lower jaw:
  • Fixed restoration
  • Ball overdenture
  • Bar overdenture
• Upper full arch:
  • Fixed restoration
  • Bar overdenture
• Please remove teeth
• Place implant and return with healing abutments and fixture level impression copings
• Place implants and return with final abutments and impression copings
• Place implants and return with final abutments and temporary restorations.

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