Skip to content
We’ve Moved!
Our new address is 140 Harold Fleming Court.
Services
About Us
Patient Information
Dentist Referrals
Contact Us
CALL: 864.576.5951
Menu
Services
About Us
Patient Information
Dentist Referrals
Contact Us
CALL: 864.576.5951
Refer a Patient
Patient Referral Form
Preferred Appointment Date
Time Preference
AM
PM
Patient First Name
*
Patient Last Name
*
Patient Phone Number
*
Please Evaluate
General Full Mouth Exam
Crown Lengthening
LANAP (Laser Surgery)
Mucogingival – attached gingiva
Mucogingival – esthetic root coverage
Local Area
Ridge augmentation
Implants
Mucogingival – frenum
Estethic gingivectomy
Gingival hyperplasia
Other
Other
Please Note Areas to Evaluate
Recent X-Rays
Needs fmx
Will mail
Will email
pa
fmx
pan
Treatment Already Completed
New patient prophy
6-month prophy
Scaling and root planing
Comments
Referring Dr. Name
*
Referring Dr. Office Name
*
Referring Dr. Phone
*
reCAPTCHA
If you are human, leave this field blank.
Submit