Online Referral

Date of Referral

Dr. Office Phone Number*

Referring Doctor*

Referring Doctor Email*

General Practitioner
Referring Hygienist
Introducing
MrMsMrsDr
Last Name
First Name

Patient Email*

Home Phone Number
Cell Phone Number
Please Evaluate
Periodontal ConditionOsseointegrated Implant TherapyCrown LengtheningCosmetic Gingival RecontouringBiopsyTissue GraftingRecessionPeriapical AbscessFrenulectomy and FiberotomyPeriodontal Maintenance CareImpacted Tooth ExposureEndodontic/Periapical SurgeryLaser Periodontal Therapy
Special Problem Areas


Other:
PLEASE CONTACT PATIENT TO SCHEDULE AN EXAMINATION APPOINTMENT.


Appointment Date
Appointment Time
AMPM
*If unable to honor appointment please give courtesy of 48 hours notice: (770) 740-0442
If you have dental insurance, be sure to bring your insurance card with you.

PLEASE PROVIDE THE FOLLOWING PERIODONTAL REFERRAL INFORMATION

Radiographs taken in the last 3 years PANFMXPABW
Being sent with PatientMailed to usEmailed to us
Last Prophylaxis
Last Scale/Root Planing
Major Restorative Treatment Planned/Completed
Any Other Information

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