Periodontal Referral Form

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

    Files & Images

    When submitting large files, please wait until you have the success message! Max File Size 5mb per file uploaded.

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

    Contact Us

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    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 schedule your appointment today!
      No referral is necessary.