New Patient Referral Form
New Patient Referral Form Can Be Also Be Downloaded and Faxed For Your Convenience.

Patient Information:
 
Referred By:
Patient Name:
Email:
Home Phone:
Cell Phone:
Address:
Patient:

Health Information:

Is the patient healthy? 
Is patient a smoker?
Health Concerns:



Medications:
Drug Allergies:

Periodontal Status:

(Please email copy of periodontal charting(s) current and > 1 year.)
Periodontal Issues:
Treatments Performed:


If Implants Placed: 
Please note reason for 
extraction, if applicable: 
 
Esthetic Area? 
Is restorative height an 
issue? 

Over Denture Case:




Current Denture 
Fabricated When?
Other Information:

Radiographs and Study
Models


Check Available:




 

Treatment Options 
Discussed
with Patient:


Appointment Status


 

Additional Comments:


 
Enter the code shown above:

Submit Appointment Request
Perio Risk Assessment

The American Academy of Periodontology's risk assessment test will help you see if you are at risk for having or developing periodontal (gum) disease.



For a limited time, Dr. Cook is offering patients a $150 credit towards any dental treatment if you book your appointment today! 

Call today to schedule your comprehensive exam or click the button below to learn more!


Have Additional Questions? Call Now: (910) 256-8486

We are accepting new patients in both our Wilmington and Leland offices! 
Ready to Schedule Your Appointment?
Click Here!