Dallas Periodontist | University Park

We greatly the appreciate the opportunity to partner with you to achieve superior care for your patients. Please do not hesitate to contact us regarding referrals and patient care. The security and privacy of your personal data is one of our primary concerns and we will take every precaution to protect it.

"*" indicates required fields

Referring To:*

Beth M. Tomlin, DDS, MS

Stephanie C. Bowers, DDS, MS

Either

Patient Name*

First Last

Date Of Birth*

Please reach out and contact this patient*

Yes

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Phone Number*

Referring Doctor and Practice*

Referring Practice Email*

Referring Practice Phone Number*

Nature of Referral and Other Important Information

Please upload any supporting images or files. These files may be no larger than 5mb in size. A total of 20 files may be attached. If files are too large to attach, or you have more than 20 attachments, please send to Info@ParkCitiesPerio.com

File Uploads

Drop files here or

Max. file size: 5 MB, Max. files: 20.

Referring Dentists