Referral Form Referred by: Patient's name: Patient's phone number: Referrer email: Reason for referral: Implant(s) Implant dentures Comprehensive dental evaluation Gum disease evaluation Gum recession/grafting Gummy smile correction Laser frenectomy Tooth exposure Other: Does patient have active decay or other disease? Yes No Restorative treatment plan: RADIOGRAPHS Recent radiographs: Radiograph options: Attached to this form Emailed to info@clagettperio.com Please take as needed File Upload Drop a file here or click to upload Choose File Maximum file size: 20MB Submit If you are human, leave this field blank.