REFERRAL FORM

Thank You for Your Referral


We appreciate your confidence in referring to our practice. Patients may be referred to our office with our secure online Referral Form. We have taken every precaution to protect the security of patient information.

You may submit your x-rays electronically by emailing them to us. If you are referring to the Salt Lake City office please email the x-rays to knightperio@gmail.com. For the South Jordan Office, email to perio3632@hotmail.com.

Referral Form Recommendations

Our goal is to have patients feel like our office is an extension of yours. To help us accomplish this goal, we recommend reviewing the following checklist when referring a patient to Utah Periodontal Specialists.

  • Please advise us of the care you have provided and what you plan in the future so that we can reinforce your recommendations and be consistent in our treatment planning.
  • The more information we have about the patient and the treatment the better. Please include tooth number and /or quadrants associated with your patient’s treatment needs.
  • Most often, your patients will be seen first for an examination and their surgery will occur at a separate appointment.
  • Our referral form is available download here. If you have trouble submitting the online form, please email a completed form to us at [email] or send a hardcopy to 1955 South 1300 East, Suite 3, Salt Lake City, UT 84105.
  • Current x-rays are helpful. Please send all radiographic documentation on file.
  • We recommend scheduling patients while in your office. We know how busy things get, so if you call while your patient is there, we promise to do our best to quickly take care of your request.

We welcome your phone calls and emails to discuss treatment prior to your patients coming in. The more information we share the better care the patients receive. If you have any questions, concerns or suggestions, feel free to contact us to speak with a doctor. Our Treatment coordinators are available to help facilitate comprehensive treatment planning.

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