Currently Accepting New Patients

Refer a Patient

Patient’s First Name

Patient’s Last Name

Patient’s Phone Number

Patient’s Date of Birth

Patient’s Address

State

Zip

Referring Dental Office

Referring Dentist

Referral Office Email

Patient Appointment

P.S. Preferred Location

Date of last panorex or FMX ( *Please Attach Below. )

Date of last set of bitewing x-rays

Patient’s last periodontal maintenance appointment

Active treatment plan

Areas of concern

Additional comments

Signature Agreement

I agree that by typing my name in the field below I am signing this form.

Type Your Name to Sign

The mission of Periodontal Specialists is to improve the quality of life of our patients through the diagnosis and treatment of their periodontal disease and through rehabilitation with dental implants.

Links

Service Areas

Copyright © Periodontal Specialists, P.A.

img.wp-smiley,img.emoji{display:inline !important;border:none !important;box-shadow:none !important;height:1em !important;width:1em !important;margin:0 .07em !important;vertical-align:-.1em !important;background:none !important;padding:0 !important;}.wp-block-button__link{color:#fff;background-color:#32373c;border-radius:9999px;box-shadow:none;text-decoration:none;padding:calc(.667em + 2px) calc(1.333em + 2px);font-size:1.125em;}.wp-block-file__button{background:#32373c;color:#fff;text-decoration:none;}body{--wp--preset--color--black:#000;--wp--preset--color--cyan-bluish-gray:#abb8c3;--wp--preset--color--white:#fff;--wp--preset--color--pale-pink:#f78da7;--wp--preset--color--vivid-red:#cf2e2e;--wp--preset--color--luminous-vivid-orange:#ff6900;--wp--preset--color--luminous-vivid-amber:#fcb900;--wp--preset--color--light-green-cyan:#7bdcb5;--wp--preset--color--vivid-green-cyan:#00d084;--wp--preset--color--pale-cyan-blue:#8ed1fc;--wp--preset--color--vivid-cyan-blue:#0693e3;--wp--preset--color--vivid-purple:#9b51e0;--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple:linear-gradient(135deg,rgba(6,147,227,1) 0%,#9b51e0 100%);--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan:linear-gradient(135deg,#7adcb4 0%,#00d082 100%);--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange:linear-gradient(135deg,rgba(252,185,0,1) 0%,rgba(255,105,0,1) 100%);--wp--preset--gradient--luminous-vivid-orange-to-vivid-red:linear-gradient(135deg,rgba(255,105,0,1) 0%,#cf2e2e 100%);--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray:linear-gradient(135deg,#eee 0%,#a9b8c3 100%);--wp--preset--gradient--cool-to-warm-spectrum:linear-gradient(135deg,#4aeadc 0%,#9778d1 20%,#cf2aba 40%,#ee2c82 60%,#fb6962 80%,#fef84c 100%);--wp--preset--gradient--blush-light-purple:linear-gradient(135deg,#ffceec 0%,#9896f0 100%);--wp--preset--gradient--blush-bordeaux:linear-gradient(135deg,#fecda5 0%,#fe2d2d 50%,#6b003e 100%);--wp--preset--gradient--luminous-dusk:linear-gradient(135deg,#ffcb70 0%,#c751c0 50%,#4158d0 100%);--wp--preset--gradient--pale-ocean:linear-gradient(135deg,#fff5cb 0%,#b6e3d4 50%,#33a7b5 100%);--wp--preset--gradient--electric-grass:linear-gradient(135deg,#caf880 0%,#71ce7e 100%);--wp--preset--gradient--midnight:linear-gradient(135deg,#020381 0%,#2874fc 100%);--wp--preset--font-size--small:13px;--wp--preset--font-size--medium:20px;--wp--preset--font-size--large:36px;--wp--preset--font-size--x-large:42px;--wp--preset--spacing--20:.44rem;--wp--preset--spacing--30:.67rem;--wp--preset--spacing--40:1rem;--wp--preset--spacing--50:1.5rem;--wp--preset--spacing--60:2.25rem;--wp--preset--spacing--70:3.38rem;--wp--preset--spacing--80:5.06rem;--wp--preset--shadow--natural:6px 6px 9px rgba(0,0,0,.2);--wp--preset--shadow--deep:12px 12px 50px rgba(0,0,0,.4);--wp--preset--shadow--sharp:6px 6px 0px rgba(0,0,0,.2);--wp--preset--shadow--outlined:6px 6px 0px -3px rgba(255,255,255,1),6px 6px rgba(0,0,0,1);--wp--preset--shadow--crisp:6px 6px 0px rgba(0,0,0,1);}:where(.is-layout-flex){gap:.5em;}:where(.is-layout-grid){gap:.5em;}body .is-layout-flow > .alignleft{float:left;margin-inline-start:0;margin-inline-end:2em;}body .is-layout-flow > .alignright{float:right;margin-inline-start:2em;margin-inline-end:0;}body .is-layout-flow > .aligncenter{margin-left:auto !important;margin-right:auto !important;}body .is-layout-constrained > .alignleft{float:left;margin-inline-start:0;margin-inline-end:2em;}body .is-layout-constrained > .alignright{float:right;margin-inline-start:2em;margin-inline-end:0;}body .is-layout-constrained > .aligncenter{margin-left:auto !important;margin-right:auto !important;}body .is-layout-constrained > :where(:not(.alignleft):not(.alignright):not(.alignfull)){max-width:var(--wp--style--global--content-size);margin-left:auto !important;margin-right:auto !important;}body .is-layout-constrained > .alignwide{max-width:var(--wp--style--global--wide-size);}body .is-layout-flex{display:flex;}body .is-layout-flex{flex-wrap:wrap;align-items:center;}body .is-layout-flex > *{margin:0;}body .is-layout-grid{display:grid;}body .is-layout-grid > *{margin:0;}:where(.wp-block-columns.is-layout-flex){gap:2em;}:where(.wp-block-columns.is-layout-grid){gap:2em;}:where(.wp-block-post-template.is-layout-flex){gap:1.25em;}:where(.wp-block-post-template.is-layout-grid){gap:1.25em;}.has-black-color{color:var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-color{color:var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-color{color:var(--wp--preset--color--white) !important;}.has-pale-pink-color{color:var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-color{color:var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-color{color:var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-color{color:var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-color{color:var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-color{color:var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-color{color:var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-color{color:var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-color{color:var(--wp--preset--color--vivid-purple) !important;}.has-black-background-color{background-color:var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-background-color{background-color:var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-background-color{background-color:var(--wp--preset--color--white) !important;}.has-pale-pink-background-color{background-color:var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-background-color{background-color:var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-background-color{background-color:var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-background-color{background-color:var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-background-color{background-color:var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-background-color{background-color:var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-background-color{background-color:var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-background-color{background-color:var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-background-color{background-color:var(--wp--preset--color--vivid-purple) !important;}.has-black-border-color{border-color:var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-border-color{border-color:var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-border-color{border-color:var(--wp--preset--color--white) !important;}.has-pale-pink-border-color{border-color:var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-border-color{border-color:var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-border-color{border-color:var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-border-color{border-color:var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-border-color{border-color:var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-border-color{border-color:var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-border-color{border-color:var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-border-color{border-color:var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-border-color{border-color:var(--wp--preset--color--vivid-purple) !important;}.has-vivid-cyan-blue-to-vivid-purple-gradient-background{background:var(--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple) !important;}.has-light-green-cyan-to-vivid-green-cyan-gradient-background{background:var(--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan) !important;}.has-luminous-vivid-amber-to-luminous-vivid-orange-gradient-background{background:var(--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange) !important;}.has-luminous-vivid-orange-to-vivid-red-gradient-background{background:var(--wp--preset--gradient--luminous-vivid-orange-to-vivid-red) !important;}.has-very-light-gray-to-cyan-bluish-gray-gradient-background{background:var(--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray) !important;}.has-cool-to-warm-spectrum-gradient-background{background:var(--wp--preset--gradient--cool-to-warm-spectrum) !important;}.has-blush-light-purple-gradient-background{background:var(--wp--preset--gradient--blush-light-purple) !important;}.has-blush-bordeaux-gradient-background{background:var(--wp--preset--gradient--blush-bordeaux) !important;}.has-luminous-dusk-gradient-background{background:var(--wp--preset--gradient--luminous-dusk) !important;}.has-pale-ocean-gradient-background{background:var(--wp--preset--gradient--pale-ocean) !important;}.has-electric-grass-gradient-background{background:var(--wp--preset--gradient--electric-grass) !important;}.has-midnight-gradient-background{background:var(--wp--preset--gradient--midnight) !important;}.has-small-font-size{font-size:var(--wp--preset--font-size--small) !important;}.has-medium-font-size{font-size:var(--wp--preset--font-size--medium) !important;}.has-large-font-size{font-size:var(--wp--preset--font-size--large) !important;}.has-x-large-font-size{font-size:var(--wp--preset--font-size--x-large) !important;}.wp-block-navigation a:where(:not(.wp-element-button)){color:inherit;}:where(.wp-block-post-template.is-layout-flex){gap:1.25em;}:where(.wp-block-post-template.is-layout-grid){gap:1.25em;}:where(.wp-block-columns.is-layout-flex){gap:2em;}:where(.wp-block-columns.is-layout-grid){gap:2em;}.wp-block-pullquote{font-size:1.5em;line-height:1.6;}section.elementor-section.elementor-top-section.elementor-element.elementor-element-c833fd1.she-header-yes,.she-header-transparent-yes{background-color:rgba(255,255,255,63%) !important;}.single-post h2{font-size:35px !important;}.single-post h3{font-size:30px !important;}.single-post h4{font-size:25px !important;}.gform_button.button{font-family:var(--e-global-typography-accent-font-family),Sans-serif;font-size:var(--e-global-typography-accent-font-size);font-weight:var(--e-global-typography-accent-font-weight);line-height:var(--e-global-typography-accent-line-height);fill:var(--e-global-color-d795aec);color:var(--e-global-color-d795aec);background-color:var(--e-global-color-secondary);border:0 !important;}.gform_wrapper.gravity-theme .gfield textarea.large{height:170px;}.gform-body.gform_body h3,.gform-body.gform_body h2{font-size:25px;}.elementor-accordion-item h3{font-size:18px;line-height:unset !important;}.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff;}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent;}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px;}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em;}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px;}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block;}.elementor-widget-image{text-align:center;}.elementor-widget-image a{display:inline-block;}.elementor-widget-image a img[src$=".svg"]{width:48px;}.elementor-widget-image img{vertical-align:middle;display:inline-block;}.elementor-heading-title{padding:0;margin:0;line-height:1;}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit;}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px;}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px;}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px;}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px;}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px;}#datetimepicker1,#datetimepicker2,#datetimepicker3{font-size-adjust:.5;}