Refer a Patient | Yant Periodontics, Grand Junction CO

Referring Office Information

I do not have a general dentist

Check this box if you are a patient submitting this referral on your own behalf without a referring dental office.

Referring Doctor *

Practice Name *

Office Phone *

Office Email *

Office Fax

Office Manager Name

Patient First Name *

Patient Last Name *

Patient Phone *

Patient Email

Date of Birth *

Office Location

Current Pain Level

Urgency

Teeth Number(s)

Clinical Notes & Reason for Referral *

Medical Alerts or Special Considerations

X-rays and/or clinical photos will be sent separately

Optional -- provide insurance details to help us verify benefits before the appointment.

Insurance Provider

Member / Subscriber ID

Group Number

Subscriber Name (if not patient)

Reach out by email and our team will get back to you promptly.

Mon - Thurs, 8:00 AM - 5:00 PM

We Receive Your Referral

Our team reviews the referral and patient information.

We Contact the Patient

We reach out to schedule at our Grand Junction office.

Treatment & Follow-Up

We provide treatment and send a detailed report back to you.

Board-certified periodontist

One convenient Western Slope office

Detailed treatment reports

Collaborative treatment planning

Same-week availability