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Referrals

Please use the secure Referral Form below when referring patients to Thunder Bay Periodontics. If you have any questions about our online referral form, please contact us directly at 1 807 768 4867. Upon submitting a successful referral to Thunder Bay Periodontics you will receive a confirmation message. If you do not see a confirmation message please confirm that you have completed all mandatory fields. Thank you for referral!

Patient Information
Referral Information
Reason For Referral
Comprehensive Exam
Pocketing Implants, Multiple Quadrants Furcation Involvements Pre-Prosthodontic Crown Lengthening, Multiple Quadrants Pre-Orthodontic Mucogingival Exam, Multiple Quadrants
Specific Exam
Pocketing, Single Site Implant, Single Site Furcation Involvement Crown Lengthening, Single Site Mucogingival Exam, Single Site
Current Records
Radiographs (Within 2 Years)
FMX Panoramic Periapical(s) Tomography Bitewing(s)
Delivery
Being mailed No X-Rays Being Emailed Please Take X-Rays Given to Patient
Models
Yes No
Implants
Referred System
Nobel Biocare Straumann
Files & Images
Select Files
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