MK PERIODONTICS AND IMPLANTS
  Minou Karbakhsch DDS, MSD
  Michi Katafuchi DDS, MSD
  Diplomates of the American Board of Periodontology
 
2302 S Union Avenue, Building C, Suite 27
Tacoma, WA 98405
Phone (253)752-6336, Fax (253)752-5655
info@mkperio.com 

 
 
 

REFERRAL

 
Patient's Name
Referrer Email

Premedication Required

    

Condition/Treatment

 

We are committed to excellence in patient care. Thank you for your confidence and trust.

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold MK Periodontics & Implants, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. 

 By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents.