Dental Referral - Highlands Ranch Periodontics

We appreciate all referrals from our local dentists and will provide the best in periodontal care for your patients. Please use the Referrals Pads we hand out or Our Digital System below. To use our digital system, please follows these steps:

Fill out the form below
Submit
The form will be emailed to you (the referring doctor) and the patient based on the emails entered below. You can then either print off a copy of the email for the patient, or print out the form submission confirmation on this page.
Done

Patient Name(Required)

First Last

Patient Email(Required)

Patient Phone Number(Required)

Referring Doctor Name(Required)

Referring Doctor's Email(Required)

Reason for Referral(Required)

Consultation Only

Please Evaluate & Treat

CBCT Scan Only

Additional Instructions

None

Please Provisionalize

Impacted Tooth Exposure

Remarks(Required)

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