Online Referral Form For dental offices and prospective patients A PDF version of this form can be downloaded below or call the office to refer yourself or a patient in person. Referral Form PDF Referral Form Patient 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): Service Required (pick one):* 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 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? CAPTCHA