Winston-Salem Periodontics
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Referral Form

Please select one of the following options:

Digital Referral Form

The following forms can be filled and submitted online form any device (phone, tablet, laptop or desktop).

Periodontal Referral Form

Technical Note:
For digital x-rays, please e-mail them to [email protected]
Referral Form in PDF format

The following form can be downloaded to your computer, please fill it out and send it to us by fax 336-768-9011 or email.

Periodontal Referral Form (215 Kb)

Technical Note:
Our online forms use the Adobe Acrobat Plugin.
Please download the free plug-in from Adobe's website if it is not already installed on your system. It is important that you have the latest version, in order to open, fill and save our forms.

We exemplify excellence in patient care in all aspects of our practice. Our patients and referral sources know we are the most caring and professional team and we are the premier periodontal practice in the region.