If you have any questions and would like to speak with us directly at Eastside Periodontics and Implantology, give us a call directly at 503-667-2442.
Fill out the referral form below and we’ll get back to you as soon as possible.
Select Recipient (required) —Please choose an option—Gresham OfficePortland OfficeClackamas Office
Introducing (required)
Referred By (required)
Patient’s Phone # (required)
Date of Referral (required)
Date of Most Recent Radiographs (required) Films MailedFilms with PatientPlease Take FilmsRadiographs e-mailed to gresham@eastside-perio.comRadiographs e-mailed to portland@eastside-perio.com
Restorative Treatment (required) Is PlannedWill Be Planned After Periodontal EvaluationIs Not Indicated
Periodontal Treatment Completed Full Mouth DebridementScaling and Root Planning
Please Evaluate For (required) Full Mouth DebridementScaling and Root PlanningComplete Periodontal Evaluation and TreatmentLimited Periodontal Evaluation and TreatmentImplant Evaluation and Treatment
Areas of Involvement
Comments
Appointment Date
Appointment Time
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Download the referral form and fax or email it to the number/email on the form.
Referral form Gresham, Hood River, Portland
Referral form Clackamas
