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 Disease
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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
Dentist Referral Form Please provide the following patient information: Today's Date Patient’s First Name Patient’s Last Name Patient’s Home Phone Patient’s Work Phone Referred By Dentist eMail Address: Patient referred for the following treatment: Complete Periodontal Evaluation Note: Localized Area Periodontal Evaluation Note: Laser Periodontal Therapy Note: Gingival Recession/Grafting Note: Scaling/Root Planing Note: Functional Crown Lengthening Note: Esthetic Crown Lengthening (gummy smile) Note: Other Radiographs Please expose required radiographs Patient has radiographs Mailed via postal service No radiographs available Consultation Request Please call PRIOR to consulting with patient. Please call AFTER consulting with patient. Please notify me, by letter, after visit. Please send secure email regarding patient to: More Detail on this Patient
Dentist Referral Form
Please provide the following patient information:
Today's Date Patient’s First Name Patient’s Last Name Patient’s Home Phone Patient’s Work Phone Referred By Dentist eMail Address:
Patient referred for the following treatment:
Complete Periodontal Evaluation Note: Localized Area Periodontal Evaluation Note: Laser Periodontal Therapy Note: Gingival Recession/Grafting Note: Scaling/Root Planing Note: Functional Crown Lengthening Note: Esthetic Crown Lengthening (gummy smile) Note: Other
Complete Periodontal Evaluation
Note:
Localized Area Periodontal Evaluation
Laser Periodontal Therapy
Gingival Recession/Grafting
Scaling/Root Planing
Esthetic Crown Lengthening (gummy smile)
Other
Radiographs
Please expose required radiographs Patient has radiographs Mailed via postal service No radiographs available
Please expose required radiographs Patient has radiographs
Mailed via postal service No radiographs available
Consultation Request Please call PRIOR to consulting with patient. Please call AFTER consulting with patient. Please notify me, by letter, after visit. Please send secure email regarding patient to: More Detail on this Patient
Consultation Request
Please call PRIOR to consulting with patient.
Please call AFTER consulting with patient.
Please notify me, by letter, after visit.
Please send secure email regarding patient to:
More Detail on this Patient
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