Referrals – PerioClinik Dr. Freddy Fokam

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

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

6- Comments / Special Instructions:
Comments

819-790-9581

Appointment Referrals

Contact