Online Referral Form

A PDF version of this form can be downloaded below or call the office to refer yourself or a patient in person.

Patient First & Last Name*
Patient Email*
Patient Phone*
Preferred Periodontist:
- Dr. Peter Fritz
- Dr. Luisa Schuldt
- Earliest Available
Area of Treatment (pick one):
- Generalized
- Specific Area/Tooth
Specific Tooth/Area (if known):
Reason for Referral:*
- Select All
- Implant Consultation
- Implant Maintenance
- Comprehensive Periodontal Examination (for Periodontal Disease)
- CBCT Imaging
- Evaluation of Recession/Gum Grafting
- Biopsy/Pathology
- Atraumatic Extraction/Socket Preservation
- Crown Lengthening
- Tooth Exposure
- Frenectomy
- Additional supportive periodontal therapy
Are you/your patient interested in Sedation Dentistry?
- Yes
- No
- Maybe. Tell me more.
Available Imaging:
- No current diagnostic radiographs available
- Current radiographs being sent by CDA Secure Send (for dental offices only)
- Current radiographs being sent with patient
- Current radiographs being sent by Canada Post
- Current radiographs being sent by secure email to [email protected]
Referred by:
- Self
- Dentist
- Other
Name of Referring Dentist (if applicable):
Referring Dentist's Contact Information (if applicable):
How did you hear about us?
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