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 use our Contact Us form below or 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.

Request An Appointment

Contact Magnolia Pedraza, DMD, MS

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment. Note: If you are an existing patient, this contact form should not be used to communicate private health information.
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