Referring Doctors

We understand that close coordination is key to providing the best over-all outcome with patients. This is especially true in implant case planning where we begin our portion of care with your restorative vision in mind.

If you would like to communicate directly to our office regarding clinical or other issues please fill out the form below and it will be emailed to us. In order to prevent spam, we have chosen not to list our email addresses directly on the website.

You may also download our Doctor Referral Form here.

We appreciate the opportunity to collaborate with you for exceptional patient care.

Please introduce your patient below

Patient's Name*
Contact Phone Number
Patient's Date of Birth
Preferred Location*
- Sandy Hill
- Centertown
- Carling
Referring Doctor's Name*
Doctor's Email*
Office Name*
Office Phone*
Radiographs/Documents
Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 16 MB, Max. files: 5.
Concerning Message
Name
This field is for validation purposes and should be left unchanged.

CONFIDENTIALITY

This form sends a non-secure email to our office email address. Please do not include Protected Health Information.

Referring Doctors

Please introduce your patient below

CONFIDENTIALITY

Periodontal Associates in Sandy Hill

Periodontal Associates in Centertown

Periodontal Associates on Carling