On-Line Referral

Please fill in the referral below and our team will contact your patient to schedule an appointment. Please e-mail any additional information/attachments to info@gtaperio.com.

Patient Name *

First

Last

Patient Phone Number *

Patient E-mail:

Purpose of Referral *Periodontal ConsultEndo ConsultProstho ConsultGum Recession ConsultDental Implant ConsultcbCT (specify location and if measurements needed below)

Preferred Doctor for patient to see: *First Available PeriodontistDr. Reza Termei – PerioDr. Jaffer Kermalli – PerioDr. Dina Zahedi – PerioDr. Shawn Robinson – PerioFirst Available EndodontistDr. Amir Azarpazhooh – EndoDr. Annie Shrestha – EndoDr. Majid Zakeri – ProsthoDr. Elahe Behrooz – ProsthoHaseeb Hafeez – Denturist

Referring Dentist/Practitioner *

Referral Contact Info (i.e. your e-mail and/or phone #) *

Reason for referral (Specify tooth/teeth): *

cbCT – Specify area of interest or which jaw to image and if measurements are required.

Upload files. Please upload radiographs in .JPG format.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Date of radiograph

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