Referral Form
You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.
First Name
Last Name
Date of Birth
Phone Number
Address
Email
Reason(s) for referral
Periodontics
Recession
Crown lengthening
Implant(s)
Mucogingival Lesion
Aesthetic Concerns
Canine Exposure
Treatment under GA preferred?
Yes
No
Maybe
Additional Comments
Relevant radiographs taken in the last 12 months
PA's/BW's
Attached
Emailed
None applicable
OPG
Attached
Emailed
None applicable
CBCT
Attached
Emailed
None applicable
Referring Dentist details
Referring Dentist
Provider Number
Practice
Phone Number
Email
Date of appointment (if made)
If appointment not made:
Patient will call for appointment
Patient needs to be called
Upload File
Select a File
Submit