Referring Doctor Form

The practice of Magnolia Pedraza, DMD, MS has provided a referral form for our referring doctors. Please click the button below to download a PDF version of the form to print and fill out. You may fax the completed forms to us. Our fax numbers are 217-876-0601 (Forsyth) and 217-787-0425 (Springfield).

Doctor Referral Form download button

 
Please call us if you have any questions: Forsyth IL Periodontal Office Phone Number 217-876-0547 (Forsyth) or Springfield IL Periodontics Office Phone Number 217-787-0422 (Springfield).

Technical Note:

If you are not able to open this file, you may need to download Acrobat Reader for free and use it to open our Referral form.

Office Hours

Tuesday:   8:00 AM - 5:00 PM
Wednesday:   8:00 AM - 5:00 PM
Friday:   8:00 AM - 12:00 PM