Referral Form

toothjpgGregory Davis, DMD,PC
325 Meeting House Lane
Building #1
Southampton, NY 11968
T: 631.287.3600
F: 631.614.7607
E: [email protected]


Appointment Date:

Appointment Time:

Referred by Doctor:

Please circle all that apply:

Comprehensive Examination
Limited Examination
Periodontal Maintenance
Scaling and Root Planing
Sinus Elevation
Crown Lengthening
Implant Evaluation

Premedication Required:

Radiographs Forthcoming or Needed: