Referral Form

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Doctors *Sarmad Paydar, DDS MSKyu Jin Lee, DDS, MSDJames Zaiger, DDS, MSGordon Douglass,DDSFirst Available

Preferred Location * Folsom phone: 916 | 984.9308 Records@FolsomPerio.com 1631 Creekside Dr. Suite 103 Folsom, CA 95630 Roseville phone: 916 | 786.7070 Gs.Perio.Office@GSDentalCo.Com 2550 Douglas Blvd. Suite 100 Roseville, CA 95661 Sacramento phone: 916 | 483.4964 FrontOffice@GSDentalCo.Com 3960 El Camino Ave. Suite 1 Sacramento, CA 95821

Introducing

Date

From Dr

Patient Phone

PERIODONTAL CONCERNComplete Periodontal ExaminationLimited Periodontal EvaluationCrown Lengthening(s)Extraction(s)Recession(s)FrenectomyImplant(s)Extraction(s)Bone GraftPeri-implantitisBiopsyAll on XOther

Special Instructions or Comments

HYGIENE/PERIODONTAL MAINTENANCEPeriodontistAlternatingReferring Dentist

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Contact info | Roseville

Phone: 916.786.7070
Fax: 916.786.9656
Email: Gs.Perio.Office@GSDentalCo.Com
Address: 2550 Douglas Blvd.
Suite 100 Roseville, CA 95661

Contact info | Folsom

Phone: 916.984.8404
Fax: 916.984.9308
Email: Records@FolsomPerio.com
Address: 1631 Creekside Dr.
Suite 103 Folsom, CA 95630

Contact info | Sacramento

Phone: 916.483.4964
Fax: 916.483.6380
Email: FrontOffice@GSDentalCo.Com
Address: 3960 El Camino Avea.
Suite 1 Sacramento, CA 95821

Golden State Dental Co

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