Refer a Patient

We appreciate the confidence you've placed in us to provide your patients with the complete periodontal care they need, and we thank you for recommending our practice to your patients.

If you are here to refer a patient to our practice, please provide us with the information either by downloading this PDF or completing the form below:

Practice Information

Bold Fields are required.

Referring Doctor: First and Last Referring Doctor Phone Number: Referring Office Email:

Referral Information

Doctor Preference (please check all boxes that apply): Dr. Vana Andreou Dr. Lisa Richardson Dr. Charles Alleyn Dr. Catherine Gagnon Dr. Sophie R. Couto No Preference

Name of the Patient You are Referring: First and Last Patient's Date of Birth: Patient's Phone Number: Patient's Cell Number: Patient's Work Number: Patient's Email Address:

Radiographs Sent?

Yes No

When Were They Sent?

Reason for Referral: Periodontal / Pockets (Comprehensive)Periodontal / Pockets (Specific)Recession (Comprehensive)Recession (Specific)ExtractionImplantExposureOther Restorative Plan: Pertinent Medical History or Special Considerations: Comments:

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Submit Referral

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