Appointment Referrals

Fill out the form below to refer a patient to the PerioClinik. We look forward to speaking with you about your patient.

1- Referring Dentist/Hygienist Information:
First and Last Name

Phone
Email

2- Patient Information:

First and Last Name
Date of Birth

Phone
Email

3- Reason for Referral:
Select the reasons
Full Periodontal ExamPre-orthodontic ExamGingival GraftBone GraftDental ImplantExtractionsCrown LengtheningImpacted Tooth ExposureTreatment of PeriodontitisTreatment of Peri-implantitisSedation3D X-rayOral Medicine / PathologyOther

4- Select the concerned tooth numbers:
Select the concerned teeth

1817161514131211212223242526272848474645444342413132333435363738

5554535251616263646585848382817172737475

5- Attach images / radiographs or documents (png, jpeg, PDF...):

❌

6- Comments / Special Instructions:
Comments

Download the Referral Form to submit via fax or email. Fax: 819-201-8615

Schedule a Consultation

Contact

403-10 Allée de Hambourg
Gatineau, QC J9J4K2

Phone: 819-790-9581

Fax: 819 201 8615

info@perioclinik.ca