Referring Doctors

The following form is for doctors only. If you would like to schedule an appointment please click here!

You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the SUBMIT button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.
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Referring Doctor

Date

Patient Name*

Phone*

New Patient

Requesting to see

Remarks

Please submit x-rays and other documentation by email to info@perioatlanta.com. Thank you.

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