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PATIENT
REFERRAL
FORM

Please fill out our referral form.
Once received, we will contact your patient and schedule a consultation appointment.

Thank you for your trusting our practice and your kind referral! If you have any questions, please call or email us.

Tooth Number(s) in reference
Radiograph taken? (if yes, please send us a copy)

Address: 3001 Academy Rd, Suite 250, Durham, NC 27707 Tel: 919-489-3204 Email: smile@drbashperio.com

Ellie Bash, DDS, MS, Diplomate of the American Board of Periodontology

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Where to Find Us

Location

3001 Academy Rd, Suite 250
Durham, NC 27707

(We are across from convenience store. Once you enter the driveway, please stay on the left - we are the last building at the corner).

Mon-Wed: 7:30am - 4:00pm
Thursday: 7:30am - 3:00pm
Friday: Open only for LANAP & Surgeries
Sat & Sun: Closed

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rEFERRING DENTISTS

At Ellie Bash Periodontics & Implants, we truly value the wonderful relationships we’ve built with our referring dental partners. It means the world to us that you trust us with your patients’ care; it’s one of the greatest compliments we could receive! 

 

We've found that patients really appreciate when their dental team works closely with trusted specialists for more complex treatments. Teamwork makes the dream work!
 

If you ever have any questions about a case or how we can best support your team, please don’t hesitate to reach out – we are always happy to help!

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