Periodontal Referral

Periodontal referral form.

We treat the surgical phase and return your patient to you for restorative care and recall. Complete this form and attach any radiographs — we contact the patient within one business day and report back after every case.

1 Referring practice
2 Patient
3 Reason for referral

Tick everything that applies — we will confirm the plan at consult.

Radiographs sent

Attach a pano, FMX, CBCT export or clinical photographs — JPG, PNG, PDF, DICOM or a zip, up to 9 MB in total. Larger studies: send the referral now and email reception@anewyougj.com or drop a link to your imaging portal in the notes below. Do not hold the referral waiting for images.

4 Medical history

Drives surgical planning, sedation and medical insurance eligibility.

Medically complex patients can often be billed to medical rather than dental, preserving the dental benefit for your restorative work. Not every patient will qualify — coverage depends on the payer, the plan and documented medical necessity. We verify eligibility before treatment is scheduled.
5 Patient's physician

Required where medical billing or medical clearance may apply.

6 Timing

During office hours — Monday to Thursday, 8:30 am to 4:00 pm — call (970) 763-1522. After hours, text Dr. Yant directly at (301) 616-7734.

7 Sign and send

Typing your name here has the same effect as signing the paper form.

Sent securely to reception@anewyougj.com. We contact the patient within one business day and confirm receipt with your office.
Urgent? Call (970) 763-1522. After hours, text Dr. Yant on (301) 616-7734.

Referral received.

It's with our front desk. We'll contact your patient within one business day and confirm back to your office. If this is urgent, call (970) 763-1522 as well.

1

We contact the patient within one business day and book the consult.

2

You receive our findings and the proposed plan in writing.

3

We treat the surgical phase and follow the patient through healing.

4

Patient is dismissed back to your recall with a written summary.

Call Text Request Appt