Solana Beach ReferralsSolana Smiles Implant Center652 Stevens Ave Solana Beach, CA 92075 Phone: 858-481-5210, Fax: 858-481-0502 "*" indicates required fields Appointment Request* Azita Vakili, DMD Certified Specialist in Prosthodontics Members of American Dental Association, American College of Prosthodontists, California Dental Association, American Association of Women Dentist, Fellow of Internal College of Oral Implantologists Referring Doctor’s Name:* Date* DD dash MM dash YYYY Referring Office Phone:Please enter a valid phone number.Referring Office Email: Patient’s Name:* Phone:*Patient’s Email:* Preferred Scheduling Method:* Our office to call and schedule patient Patient will call to schedule appointment Need our office to contact your office first Medical Alert:*Radiographs:* With patient Emailed Take new None Referred For / Consultation and/or Diagnosis:* Premed Patient Limited Prosthodontic Consultation Complex Prosthodontic Evaluation Implant Prosthodontics / Reconstruction Aesthetic Evaluation or Consultation Unknown Implant or Broken Component Dentures (Traditional or Overdenture) Sleep Apnea Evaluation / Treatment Removable Partial Dentures (RPD) TMJ / TMD Evaluation / Bite or Occlusion Pre-Radiation or Joint Replacement Evaluation Please send me a consultation report by:* Email Mail Phone call Please Indicate your Follow-up Preference:* Patient to return to our office for recare appointments I prefer your office to follow up with recare CommentsCommentsThis field is for validation purposes and should be left unchanged.
