For Dental Colleagues

Referring a Patient
to Our Office

We value your referral and the importance of effective communication between our offices. We will always strive to provide you with the most up-to-date progress of your patient's diagnosis and treatment.

For Dental Colleagues

Referring a Patient
to Our Office

We value your referral and the importance of effective communication between our offices. We will always strive to provide you with the most up-to-date progress of your patient's diagnosis and treatment.

Thank You for Your Referral

Thank you for your time and referral. This form is developed for your convenience — please feel free to submit as little or as much information as you would like. Please do not hesitate to contact us with any questions.

Fax

352.589.6204

Why Refer to a Periodontist?

The success of dental implants and periodontal treatment depends on specialist expertise. Dr. Richardson will evaluate your patient clinically and radiographically, provide a comprehensive treatment plan, and keep you informed at every stage of care.

We will always provide timely updates on your patient's diagnosis and treatment progress, and we welcome your calls with questions at any time.

Patient Information

Name
Address

Referring Doctor Information

Doctor Name

Reason For Referral

Checkboxes

Tooth Chart

Check all teeth of concern.
Upper (1-16)
Lower (17-32)

Periodontal Treatment History

Checkboxes

Radiographs

Multiple Choice

Additional Information

Fields marked * are required. Your referral will be reviewed promptly.

Questions? Call us at 352.589.1973 or fax to 352.589.6204.