Patient Referral Form

Eric Blasingame DDS, MS
Board Certified Periodontist

William Liska DDS
Board Eligible Periodontist

teamperiodontics.com

Redding 530.241.3302

Reno 775.447.1191

Patient Information

Date Referred:

Referring Doctor:

Patient Name:

DOB:

Email:

Phone Number:

--- Select Location ---

Imaging Provided

FMX emailed to intake@teamperiodontics.com

CT Scan taken sent by cloud/USB/Disc

Take a new FMX and share it with us

Evaluation For

Gum Disease:

Gum Recession:

Tooth Removal:

Dental Implants:

Oral Pathology:

Other:

If you need help with this form or want to see if your patient can be seen the same day, please call our office.
Redding: 530.241.3302 | Reno: 775.447.1191

Additional Information:

Eric Blasingame DDS, MS
Board Certified Periodontist

William Liska DDS
Board Eligible Periodontist

teamperiodontics.com

Redding 530.241.3302

Reno 775.447.1191

Redding

384 Hartnell Ave. Suite A.
Redding CA 96002

Phone: 530.241.3302

Reno

855 West 7th St. #130
Reno NV, 89503

Phone: 775.447.1191

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