Fill in the fields on the form by using the tab key to move from field to field. When you have completed the form, click on the SUBMIT FORM button at the bottom of the page.

1. leave this blank
   
   do not change value
   

2. Referring Doctor / Practice Information

   Referring Doctor *
   
   Referring Doctor Phone *
   
   Referring Doctor Email *
   

3. Patient Information

   Patient’s Name *
   
   Date of Birth *
   
   Home Phone
   
   Cell Phone
   
   Work Phone
   
   Address
   

4. Please evaluate for:

   Full periodontal evaluation
   Local periodontal evaluation
   

   Soft tissue grafting
   

   Biopsy
   

   Crown lengthening
   

   Canine exposure
   

   Tooth extraction/Ridge preservation
   Implant placement
   

   Ridge augmentation (soft/hard tissue)
   

   Sinus lift / Augmentation
   

   Sedation (Intravenous or N²O +O²)
   

   CBCT and Analysis
   

   Intraoral Location / Additional Information
   

5. Radiographs

   Tar Heel Periodontics will take new radiographs (Preferred)
   
   X-rays will be sent (indicate source)
   
   with patient
   
   by mail
   
   by email ([email protected])
   
   as part of this form
   
   Date of Radiographs
   
   Type of Radiographs
   

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   Upload Radiographs

   Radiograph file(s) may be attached to your referral form.

   File 1
   
   File 2
   
   File 3
   
   File 4
   
   File 5
   

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6. Notes / Additional Information
   
7. Enter the verification code
   
    
   
8. I would like to receive a copy of this referral
   

9. ---

   * please check your entries prior to submitting form
   

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