Dentist Referral Are you a dentist or dental provider looking to refer a patient to our periodontal specialist? Refer periodontics patients to our periodontist by using our secure online form. Periodontist Referral Dr. Sherif Said Dr. Freddy Fokum Reason for periodontist referral: Periodontal Disease/Gum Pockets Gum Recession/Gingival Graft Crown-Lengthening Biopsy Implants Oral Surgery Other Other IV Sedation Referral Dr. Kirsty Large Reason for IV sedation referral: Extractions Crown & Bridge General Restorative Periodontal Care Endodontic Therapy Implants Orthodontist Referral Dr. Ahmed Rizk Reason for orthodontist referral: Invisalign Crowding Spacing Crossbite(s) ( Anterior, Posterior ) Mixed dentitional consideration ( serial extractions, space maintenance ) Other/specific problem We are introducing: First Last Date of Birth MM slash DD slash YYYY Email PhoneAppointment* Patient has an appointment Patient to call for an appointment Please call patient for an appointment CommentsPlease provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.Relevant HistoryIndicate any special factors –either dental or medical –such as allergies and medical problems relevant to diagnosis and treatment.Digital Radiographs* Attached Patient to Bring No Radiographs Radiographs Panoramic Bitewing Periapical Select all that appliesReferring Clinic Name Referring Dentist Name:* Referring Dentist Phone Number* Referring Dentist Email* Date of Referral MM slash DD slash YYYY