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Angela Gum

Thank you for choosing to refer to Capital City Periodontics! We appreciate your trust and the opportunity to serve your patients.

Education Videos Referral FOrm

Patient Education Videos

Gingival Recession

Periodontitis

Bridge Vs. Implant

Patient Referral Form

Please submit all the requested information below and a member of our team will be in contact with both you and your patient to coordinate next steps. Download a PDF version of this form.

Referring Doctor:

Patient Information:

Reason for Referral:

Area of Mouth:

Upper Right:

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Upper Left:

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Lower left:

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Lower Right:

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Our Locations:

Columbus • Lewis Center

(614) 591-0667

Request An Appointment

Please call (614) 591-0667 or use the form below to schedule your appointment.

Name:Phone Number:Email Address:Preferred Dates & Times:Message:

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Thank you! Your request has been received. We will call or email you to confirm your appointment date and time. To speak with someone right away, please call our office.