Referring Doctors

At Brighton Periodontal & Implant Dental Group, our periodontists and prosthodontist value the opportunity for interdisciplinary collaboration with other dental colleagues. We will ensure to coordinate any planning and care with our referring doctors. If you would like to refer to our periodontists or prosthodontist, kindly fill out the information below. You may also download a printable PDF form that may be mailed, emailed, faxed to provided to the patient to bring to their appointment.

Printable Form

Referral Information

Patient's First Name:

Patient's Last Name:

Referring Doctor's name: Referring Doctor's Phone: Referring Doctor's Email: Date:

Reason for Referral:

Comprehensive periodontal care
Periodontal regeneration
Treatment of gingival recession
Esthetic tissue contouring
Treatment of Excessive Gingival Display (Gummy Smile)
Crown lengthening
Implant site:
Peri-implant disease therapy
Alveolar ridge augmentation
Sinus augmentation
Extraction
Ridge preservation socket grafting
All-on-4 implant therapy
Vestibuloplasty
Surgically facilitated orthodontic therapy (SFOT)
Mucosal pathology
Osseous pathology

History of periodontal and implant therapy:

Prophylaxis
Scaling and root planing Date:
Periodontal Surgery Site: Date:
Tooth Extraction Site: Date:
Bone Graft Site: Date:
Dental Implant Site: Date:

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Address: 6325 Topanga Canyon Boulevard, Suite 433, Woodland Hills, CA 91367

Phone: 818-703-7733 | Fax: 818-722-1127

Address: 5700 Ralston Street, Suite 306, Ventura, CA 93003

Phone: 805-644-5284 | Fax: 805-507-5866

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