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What is Periodontal (Gum) Disease?
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HOME
ABOUT
Reviews
PROCEDURES
Cleanings & Prevention
Dental Exams & Cleanings
Dental X-Rays
Digital X-Rays
Fluoride Treatment
Home Care
Brushing and Flossing – A Simple Guide
Oral Hygiene Aids
Dental Sealants – What You Need to Know
Dental Implants
Single Tooth Replacement
Multiple Teeth Replacement
Full Arch Implant Retained Devices
Frequently Asked Questions
Dental Restorations
Composite Fillings
Root Canal Therapy
Crowns (Caps)
Fixed Bridges
Inlay Restorations
Onlay Restorations
Dentures & Partial Dentures
Cosmetic Dentistry
Porcelain Crowns (Caps)
Porcelain Fixed Bridges
Porcelain Inlays
Porcelain Onlays
Porcelain Veneers
Tooth Whitening
Zoom Teeth Whitening
Periodontal Disease
What is Periodontal (Gum) Disease?
Diagnosis
Treatment
Maintenance
Invisalign
Sedation Dentistry
PATIENT CENTRE
Patient Forms
New Patient Form
Medical History Update
5 Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
Testimonials
FAQs
BLOG
News
REFERRALS
SERVICE AREAS
Kitchener Ontario
Alpine Ontario
Bridgeport Ontario
Brigadoon Ontario
Centreville Ontario
Country Hills Ontario
View All Areas
BOOK AN APPOINTMENT
Referral Form
Referring Dentist
Referring Office:
*
Referring Dentist:
*
Date:
MM slash DD slash YYYY
Email:
*
Phone:
*
Extension
Patient Information
Patient Name:
*
First
Last
Gender:
*
Male
Female
Date of Birth:
*
MM slash DD slash YYYY
Patient’s Home Number:
Patient’s Work Number:
Extension
Patient’s Cell Number:
Reason for Referral:
General evaluation
Specific area
Implant placement
Specific Area:
Crown lengthening:
Frenectomy:
Mucogingival defect(s):
Localized periodontal defect(s):
Implant tx:
Preferred case completion:
Healing collars
Final abutments in place
Notes:
Diagnostic films:
Are needed
Patient will bring
Have been mailed
Attached
File Attachment:
Drop files here or
Select files
Max. file size: 128 MB.
Anticipated Restorative Tx:
Crown(s)
Bridge(s)
Removable prosthesis
Implant supported
Details:
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