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Periodontal Doctor's Referral Form

45 Stanley Street, Ayr, ON, N0B 1E0      519-632-8150

Dr. Kerry D'Costa strives to create personalized and comprehensive treatment plans for your patients, while ensuring a continuity of care through open communication. Our goal is to provide dentists with a trusted resource to help patients receive the best long-term periodontal care.

Patient's Name:
Dentist's Name:
Dentist's Phone #:
Dentist's E-mail:
Generalized perio exam

If yes, date of last maintenance:

Specific area of periodontal disease


Soft tissue grafting

Crown lengthening

Additonal comments

Please correspond by

If by E-mail, provide e-mail address:

Appointment Date: