Refer a Patient To West Calgary Periodontics

This periodontal referral form is for practices referring patients to West Calgary Periodontics. Please use this periodontal referral form to send us your patient’s information. Alternatively, if you do not wish to use the online form submission please download the PDF form from the link to the right. If you have any questions about this form, do not hesitate to contact us directly at (403) 727-5307 or email us at prior to submitting the form.

Please fill out the information below as completely as possible.

IMPORTANT: When you click submit, you will receive a successful confirmation message. If you do not see the confirmation message, you will need to check through the form and complete any missing information. A confirmation e-mail will be sent to you confirming the successful submission to West Calgary Periodontics.

Patient Contact Information

Reason for Referral

Single / MultipleFull Arch Replacement / All-on-4® / Pro Arch®

Gingival Grafting & Root CoverageBone Grafting / Sinus Lift

Restorative Crown LengtheningTreatment of Excessive Gingival Display

Non-Surgical TherapySurgical TherapyWisdom Tooth RemovalManagement of Implant Complications

Extractions with Ridge PreservationRidge Reduction / Tori Removal

FrenectomyTooth ExposureTAD PlacementPeriodontally Accelerated Osteogenic Orthodontics (Wilckodontics®)

Oral BiopsiesDiagnosis & Management of Oral Lesions

Oral & Nitrous SedationIV (Intravenous) Sedation

Thank you for trusting West Calgary Periodontics with your Patient Referral!

Contact Us

Quick Contact Form

Please Do Not Use This Form To Cancel Or Reschedule An Existing Appointment

Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information. Please review our privacy policy and website terms of use prior to submitting your form request.

Opening Hours

Monday: Closed

Tuesday to Friday: 8:00am to 4:00pm

Weekends & Statutory Holidays: Closed


Plenty of Free Onsite Parking


West 85th Professional Building is Wheelchair Accessible including Elevator & Washrooms

Call us at (403) 727-5307 to book your appointment today!
No referral is necessary.