Dr. Chertok Online Referral Form 2025

Practice Limited to Periodontics • Dental Implants • Laser Therapy
2620 Ashby Avenue • Berkeley, California 94705
(510) 548-0150 • fax (510) 548-0156
www.berkeleyperiodontics.com
info@berkeleyperiodontics.com
Referral Information
Referred by

First NameLast Name
Patient Info
Introducing

First NameLast Name
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Birth Date

MonthDayYear
Date
Insurance Company
Subscriber Name

First NameLast Name
Subscriber Birth Date

MonthDayYear
Date
Subscriber SSN
Referred For
Procedures
Complete periodontal evaluation and treatment
Limited area
Oral pathology
Crown lengthening
Regenerative treatment
Laser therapy (LANAP)
Implants
Sinus augmentation
Ridge augmentation / bone graft
Extraction and bone graft
Gingival augmentation
Areas of special concern
Maxillary
Mandibular
Additional Information
Comments / Proposed restorative treatment plan
List teeth that the patient has been advised for possible extraction:
Periodontal therapy to date in our office:
This patient has been in our care since:

MonthDayYear
Date
Radiographs sent
To browse / upload and submit any x-ray images please submit the form below which will redirect you to the x-ray upload webpage. The referral form and x-rays submitted will be attached together for Dr. Chertok to review.
File Upload - Upload Photos, X-Rays, or Other Files Related to Patient's Case

Accepted File Types - jpg, jpeg, png, gif
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Practice Limited to Periodontics • Dental Implants • Laser Therapy