Referring Doctors

A successful practice doesn't just happen; it is the result of a strong commitment to excellence in the professional community and in the relationships we build with our patients and colleagues. We here at Associates in Periodontics appreciate the confidence you've placed in us to provide you with the complete care you need, and we thank you for recommending our practice to your friends and family.

If you are here to refer a patient to our practice, please provide us with the information below. Once you've completed the form, click on the SUBMIT button at the bottom of the page.

Please send current x-rays or request to have us take them

Bold Fields are required.

Patient Name: First and Last Patient's Phone Number: Referring Doctor Name: First and Last

Would you like us to contact patient?

Yes No

Patient is being referred for:

Comprehensive Periodontal Examination (Probing Depths and Treatment Plan)

or

Consultation for a Single Procedure

Implant

Tooth #

Extraction/Ridge Preservation

Tooth #

Recession/Gingival Graft

Tooth #

Crown Lengthening

Tooth #

Oral Pathology/Biopsy

Tooth #

Scaling and Root Planing

Quadrants

Pocket Elimination

Quadrants Date of Last Bitewing X-ray Date of last FMX? Please send FMX or PAs for our records. Please request x-rays to be taken at the AIP Office. Comments:

Submit Referral