Online Patient Referral form

If you are a Doctor referring a patient, you may submit a referral electronically by clicking the button below, completing the Pre-Admission Registration Form with your patient’s information, and then filling out the following referral form. Up to 2 images may be included with the referral.

Alternatively, you may also download a copy of our referral form here to email directly to our office.

Referrals and x-rays can be emailed to harrisburg@periodontalassociates.com