Professional Center – West
2440 Statesville Blvd Suite 210

Salisbury, NC 28147

 

Telephone:   704-633-0272

Click here to email us

 

 

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Periodontal
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Periodontal Services

Laser Periodontal
Therapy (LPT)

Computerized Digital Radiography

Cosmetic Gum
Regeneration

Cosmetic Crown Lengthening

Functional Crown Lengthening

Preventive Maintenance Care
 

 

Patient Referral Form


Please provide the your information:

Today's Date
Patient’s First Name
Patient’s Last Name
Patient’s Home Phone
Patient’s Work Phone
Current Dentist

Patient Referred for the following treatment:

Complete Periodontal Evaluation
Evaluation for Laser Periodontal Therapy
"Gummy" Smile / Cosmetic Consultation
Localized Area Periodontal Evaluation
Gum Recession
Second Opinion
Other

Consultation Request

Please call patient to setup appointment.
Patient will call the office.

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Revised:  June 03, 2010   Any Questions E-mail: Web Master