Monday, October 16, 2017
Doctor Referral Form

Thank you for referring your patients to Central Ohio Periodontics. We have provided a few different options to submit your referral information.

Simply complete this Patient Referral Form below and click “submit” to send your patient information to us over our secure server OR download and complete our Patient Referral Form. After you have completed the form, please email or fax it to our office.

Online Referral Form
Patient Name:
Patient Phone:
Referred by Dr.:
Referring Dr. Phone:
Treatment Needed: Emergency Treatment
Periodontal Evaluation
Implant
Lanap (Laser Assisted New Attachment Procedure)
Gingival Recession
Crown Lengthening Procedure
Other:

Appointment Date:
RadDatePicker
Open the calendar popup.
Appointment Time:
Message:

 
Enter the code shown above:

Submit


"Our goal is to provide quality periodontal care and education with a gentle, friendly touch."

-Dr. Fred Sakamoto





Have Additional Questions? Call Now: (614) 575-0070

Ready to Schedule Your Appointment? Click Here!