Peak Periodontics & Implants -
Refer A Patient
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Peak Periodontics & Implants
855 W 7th St., Suite 130, Reno, NV 89503
775-447-1191
1. Patient Information
Date Referred
*
Referring Practice Name
*
Referring Practice Phone
*
Referring Doctor
*
Patient Name
*
Date of Birth
*
Email
Phone Number
*
Imaging Provided
Upload & Attach FMX
CT Scan taken sent by cloud/USB/Disc
Take a new FMX and share it with us
Upload Files
2. Evaluation For
Gum Disease
Indicate Area
Gum Recession
Indicate Area
Tooth Removal
Indicate Area
Dental Implants
Indicate Area
Oral Pathology
Indicate Area
Crown Lengthening
Indicate Area
Other
Indicate Area
If you need help with this form or want to see if your patient can be seen the same day, please call our office.
775-447-1191
3. Additional Information
Patient Name Validation
*
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