Refer a Patient

to Periodontal Associates

Online Referral Form

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

Patient Details

Please tick all that apply

Reason(s) for referral
Treatment under GA preferred?
Relevant radiographs taken in the last 12 months
Referring Dentist details:
If appointment not made:

Upload documents and/or radiographs

Upload File