Referral – Stouffville

It is easy to refer your patients to Lime Periodontics. You can simply use our instant online referral form that sends your patient’s information directly to us or just simply download a printable PDF version of the virtual form.

We will contact the patient directly to arrange an appointment.

Referring Doctor    *

Patient's First Name    *

Patient's Last Name    *

Patient's Primary Phone    *

Patient's Secondary Phone

Patient Email Address

Patient's Date of Birth

Clinical Referral

Type of Examination:

Comprehensive Periodontal ExaminationSpecific Examination:

Periodontal Disease

Gum Grafting and Plastic Surgery
Crown Lengthening
Socket Preservation
Impacted Tooth Exposure
TAD placement
Dental Implant
Sinus Elevation
Bone Grafting
Ridge Splitting
IV Sedation
Oral Sedation or N2O

Other Reason(s) or Location(s) found during initial examination:
Proceed with the required TreatmentDiscuss with the referring dentist firstother priority dental work required by the referring dentist

Radiographs    *
AttachedGiven to PatientNone Available

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