Referring Doctors

You can use the form below to submit a patient referral to our office. If you have any questions, please contact us:

• Phone: (518) 631-5988
• Email: info@cliftonparkperio.com
• Fax: (518) 631-3688

Patient Referral Form

Referring Dentist *

Patient Name *

First

Last

Patient Phone Number

Reasons for Referral – Specific Areas of Concern

• All
• Tooth # (specify in field below)

Specific Areas of Concern (Tooth #)

Periodontal Therapy

• Complete Periodontal Exam & Treatment
• Crown Lengthening
• Soft Tissue Grafting
• Gingivectomy

Implant Therapy

• Dental Implants
• Extractions & Bone Grafting

Other Services

• Biopsy
• Frenectomy
• Other Requested Service (specify in field below)

Other Requested Service

Recent Full Mouth Radiographs

• Unavailable, please take new radiographs
• Available and emailed to info@cliftonparkperio.com

Date of Radiographs

Additional Comments

Referring Dentist Office Phone Number

Referring Dentist Office Email

Submit