REFERRAL FORM

SUBMIT A REFERRAL

USE THE FORM TO SUBMIT A REFERRAL

You may also use the link below to print and/or download a PDF referral form.

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25 E. Washington St. Suite 2033 | Chicago, IL 60602

(312) 782-4068

WHO IS A QUALIFIED PERIODONTAL REFERRAL?

Patients that have the following conditions:

  • Severe chronic periodontitis
  • Moderate to severe acute or chronic periodontitis
  • Furcation involvement
  • Vertical/angular bony defect(s)
  • Aggressive periodontitis (formerly known as juvenile, early-onset, or rapidly progressive periodontitis)\
  • Periodontal abscess and other acute periodontal conditions
  • Significant root surface exposure and/or progressive gingival recession
  • Peri-implant disease
  • Any patient with periodontal diseases, regardless of severity, who the referring dentist prefers not to treat
  • Any patient that needs an extraction, bone graft, sinus bone graft, implants services, or help with one of these conditions.

PATIENTS THAT MAY BENEFIT FROM A REFERRING DENTIST OR PERIODONTIST

Any patient with periodontal inflammation/infection and the following systemic conditions:

  • Diabetes
  • Pregnancy
  • Cardiovascular disease
  • Chronic respiratory disease

Any patient who is a candidate for the following therapies who might be exposed to risk from periodontal infection, including but not limited to the following treatments:

  • Cancer therapy
  • Cardiovascular surgery
  • Joint-replacement surgery
  • Organ transplantation

PATIENTS WITH PERIODONTAL DISEASE THAT ARE LIKELY TO BENEFIT FROM A SECOND OPINION

Any patient with periodontitis who demonstrates at reevaluation or any dental examination any of the following risk factors/indicators known to contribute to the progression of periodontal diseases:

  • Early onset of periodontal diseases (prior to the age of 35)
  • Unresolved inflammation at any site (e.g., bleeding upon probing, pus, and/or redness)
  • Pocket depths >5 mm
  • Vertical bone defects
  • Radiographic evidence of progressive bone loss
  • Progressive tooth mobility
  • Progressive gum attachment loss
  • Anatomic gum deformities
  • Exposed root surfaces
  • A deteriorating risk profile

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To get answers to your questions about how you can take better care of your teeth and gums, contact us today.

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