Online Patient Referral Introducing (patient name) *Patient Telephone Number *Referring Dr. *Doctor Telephone Number *Doctor/office Email Address *Please send all relevant x-rays to our email address: office@drbradleylander.comOur team will reach out to your office to receive radiographs.Teeth Numbers1234567891011121314151632313029282726252423222120191817Please Evaluate for *Implant(s)Gingival RecessionCrown LengtheningExtraction(s)Bone/Tissue GraftSinus LiftFrenectomyAll-on-FourOsseous SurgeryOtherRemarks *Submit
