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Piedmont Oral, Facial, and Dental Implant Surgery Center

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Piedmont Oral, Facial and Dental Implant Surgery Center

3493 Forestdale, Suite 102
Burlington, NC 27215
Phone: 336-273-1000
Fax: 336-275-9919

Which Doctor would you like to refer your patient to

James W. Belcher, Jr., D.D.S.

Yes No

Steven G. Gollehon, DDS, MD, FACS

Yes No

First Available

Yes No

Patient Information

Introducing

Phone

Referred by

Notes

Xray

mailed given to patient please take no xray

Study Models

mailed given to patient please take no xray

Appointments

Please call patient for appointment

Yes No

Patient is scheduled in your office on

, 20

Please

do not

consult me before surgery is performed.

TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SUBMIT THE FORM BELOW. AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.

Did you know...

Dental implant placement continues to be the fastest growing segment of our oral surgery practice. Slowly we are seeing more insurance plans offer coverage for this exciting treatment option for our patients with missing teeth.

To assist our patients achieve ideal treatment, we offer several options for financing treatment. Depending on the financial arrangement chosen, your patient may finance their treatment interest free!

Your patients save time in our office by pre-registering online at www.piedmontoral.com.

We are deeply appreciative of your trust in referring your patients to our practice.

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Piedmont Oral, Facial, and Dental Implant Surgery Center

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Piedmont Oral, Facial and Dental Implant Surgery Center

Doctor Referral