Home
Forms Library
Periodontal referral form

Periodontal referral form 2026

periodontal referral form Preview on Page 1

See details

4 out of 5

52 votes

The document is a Periodontal Referral Form used by dentists to refer patients for various periodontal treatments. It includes sections for patient and referring doctor information, reasons for referral, previous periodontal therapy history, potential tooth extractions, premedication requirements, radiograph instructions, restorative plans, and additional comments. The form also allows the referring dentist to request communication before and after the patient's evaluation.

Here's how it works

01. Edit your periodontal referral form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send periodontal referral template via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out the periodontal referral form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the periodontal referral form in the editor.
Begin by entering the patient's name and phone number in the designated fields at the top of the form.
Next, fill in the referring doctor's name and phone number, ensuring accurate contact information for follow-up.
In the 'Reason for Referral' section, select one or more options that best describe why you are referring the patient. You can easily check multiple boxes as needed.
Specify any relevant tooth numbers and quadrants to provide clarity on the areas of concern.
Indicate if the patient has had previous periodontal therapy by selecting from the provided options.
Answer whether you have advised the patient about potential extractions and specify which teeth if applicable.
Determine if premedication is required and note any antibiotics used in that section.
Complete any additional comments or restorative plans in their respective sections to provide further context for treatment.
Finally, ensure that all necessary signatures and dates are filled out before saving or sending your completed form.

Start using our platform today to streamline your document editing and enhance your workflow!

See more periodontal referral form versions

We've got more versions of the periodontal referral form form. Select the right periodontal referral form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2007	4 Satisfied (52 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can you self refer to a periodontist?

You can refer yourself If you are concerned about your gum condition or have any questions please call and our reception staff will be pleased to help you. Alternatively please fill in the form on the Self referral page.

What happens in a periodontal appointment?

At the appointment well take your medical and social history and discuss your gum problem. Well examine your mouth. This includes checking your gums and teeth to assess inflammation and if you have any gum pockets (openings between your gums and teeth). You may also need to have X-rays.

How painful is a periodontal cleaning?

Heres a breakdown of some common treatments and their pain levels: Scaling and Root Planing (Deep Cleaning): This non-surgical treatment removes plaque and tartar buildup from above and below the gum line. Its generally considered painless, with some patients experiencing mild discomfort or sensitivity afterward.

When to refer to a periodontal specialist?

Here are some possible reasons your general dentist might refer you to a periodontist for more advanced periodontal treatment: You have a moderate or severe level of periodontal disease, with such symptoms as: Bleeding, swollen or receding gums. Loose teeth.

What does a periodontal exam consist of?

During the comprehensive periodontal exam, the dentist will evaluate the color, texture, and contour of the gums. Healthy gums are typically pink, firm, and tightly attached to the teeth. Signs of gingival disease may include redness, swelling, bleeding, and tenderness.

periodontist referral form

Periodontist Referral Form template Generic endodontic Referral form Dental Referral Form General dentistry referral Form General Oral Surgery referral form Dental referral pad Template Sample dental referral letter to specialist ADA referral

Security and compliance

At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

Learn more

What is a dentist referral form?

Your dental office likely uses referral forms to refer patients to other medical specialists. These forms contain basic information about the patient, their dental issue, and a potential treatment option that requires specialized care. Similarly, other medical professionals can refer their patients to your office.

What is a periodontal appointment?

Although every patient will have a slightly different experience, your first periodontal appointment will typically begin with a review of your dental and medical history. Next, they will examine your jaw joints, neck, and head, the structures in your throat and mouth and your gums and teeth.

What is a periodontal visit?

The periodontist will conduct a thorough examination, discuss treatment options, and create a personalized plan to address the patients periodontal needs. Periodontists are experts in treating gum and bone issues and helping patients achieve and maintain optimal oral health.