Appointment Referrals Fill out the form below to refer a patient to the PerioClinik. We look forward to speaking with you about your patient. Referring Doctor Patient Name Patient Phone Patient Email Referral For —Please choose an option—ApicoectomyBone GraftingCBCT (3D radiographs)Dental ImplantsDiagnostic ProceduresExtractionsOrthodontics Related ProceduresPeriodontal Plastic SurgeryPeriodontal ProceduresProsthodontics Related ProceduresSedationSinus AugmentationApicoectomyOther Additional Notes Upload files Download the Referral Form to submit via fax or email. Fax: 819-201-8615