You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information.

The security and privacy of patient data are one of our primary concerns and we have taken every precaution to protect it. Contact Southern Minnesota Periodontics, P.A. for more information.

  • Demographic Information

  • MM slash DD slash YYYY

  • Contact Telephone

  • Referring Information

  • Referred for the Following

  • Radiograph or Clinical Photos

    ​​​​​​​ TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SELECT THE "Complete and Send" BUTTON BELOW. AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.
  • Drop files here or
    Max. file size: 256 MB.

    • Case Notes