Referring Doctors – Paula Cohen Schlemmer, DMD, MS, PLLC

North Star Implant Studio & Periodontics

Referring Doctors

Thank you for your kind referral. Please complete the information below:

To ensure HIPAA compliance, please refrain from including any sensitive information. Kindly fax any radiographs or documents directly to our office at (972) 666-0355.

*All fields are required for a successful submission.

Patient name

Patient email address

Patient phone number

Referred by

Radiographs available

BW/PAs FMX Pano CBCT

Please select the following reason(s) for referral:

Other:

Tooth Number(s) / Site(s):

By providing my wireless phone number and/or email, I agree and give consent to receive communication from North Star Implant & Periodontics, via text message and/or email.