On-Line Referral – GTA North Periodontics & Endodontics

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 *

Preferred Doctor for patient to see: *

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.

Click or drag files to this area to upload. You can upload up to 10 files.

Date of radiograph