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.
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

YesNo
Limited area

YesNo
Oral pathology

YesNo
Crown lengthening

YesNo
Regenerative treatment

YesNo
Laser therapy (LANAP)

YesNo
Implants

YesNo
Sinus augmentation

YesNo
Ridge augmentation / bone graft

YesNo
Extraction and bone graft

YesNo
Gingival augmentation

YesNo
Areas of special concern
Maxillary

RightFrontLeft
Mandibular

RightFrontLeft
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:

Deep scaling / Root planningProphylaxisNo trx
This patient has been in our care since:

MonthDayYear
Date
The patient may need pre-medication
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.

Recent Fmx / PasRecent BWSPANOPleas take radiographs as neededDigital films have been emailedDigital films uploaded below
File Upload - Upload Photos, X-Rays, or Other Files Related to Patient's Case

Accepted File Types - jpg, jpeg, png, gif
Cancelof
Please call before / after periodontal appointment
Should be Empty:

Practice Limited to Periodontics • Dental Implants • Laser Therapy

Referral Information

Patient Info

Referred For

Procedures

Areas of special concern

Additional Information

Radiographs sent