{"id":16614,"date":"2025-06-30T07:18:30","date_gmt":"2025-06-30T14:18:30","guid":{"rendered":"https:\/\/willamette1dev.wpengine.com\/wilsonville-or\/?page_id=16614"},"modified":"2025-07-08T05:46:32","modified_gmt":"2025-07-08T12:46:32","slug":"referrals","status":"publish","type":"page","link":"https:\/\/www.willamettevalleyperiodontics.com\/wilsonville-or\/referrals\/","title":{"rendered":"Referrals"},"content":{"rendered":"<h3 style=\"text-align: center;\">Referring Doctors<\/h3>\n<p style=\"text-align: center;\">Please fill out the form below to submit it to our office. If you have any questions or need assistance, feel free to call us at <a href=\"tel:+1-503-476-1521\">(503) 476-1521<\/a>.<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f16726-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"16726\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wilsonville-or\/wp-json\/wp\/v2\/pages\/16614#wpcf7-f16726-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"16726\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f16726-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<h2>INTRODUCING\n<\/h2>\n<div class=\"ref-row\">\n\t<p><label for=\"patient-name\">Name:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required ref-input\" id=\"patient-name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-name\" \/><\/span>\n\t<\/p>\n\t<p><label for=\"referral-date\" class=\"ref-align-right\">Date:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referral-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date ref-input\" id=\"referral-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"referral-date\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"ref-row\">\n\t<p><label for=\"address\">Address:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required ref-input-wide\" id=\"address\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"ref-row\">\n\t<p><label for=\"phone\">Phone:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel ref-input-wide\" id=\"phone\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"ref-row\">\n\t<p><label for=\"referred-by\">Referred by Dr.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referred-by\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required ref-input-wide\" id=\"referred-by\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referred-by\" \/><\/span>\n\t<\/p>\n\t<p><label for=\"referring-dr-email\">Referring Dr. Email:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referring-dr-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email ref-input-wide\" id=\"referring-dr-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"referring-dr-email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"ref-row ref-two-cols\">\n\t<p><label class=\"use_label_element\"><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fmx-sent\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"fmx-sent[]\" value=\"FMX, Pano, or Bitewings have been sent\" \/><span class=\"wpcf7-list-item-label\">FMX, Pano, or Bitewings have been sent<\/span><\/span><\/span><\/span><br \/>\n<\/label>\n\t<\/p>\n\t<p><label for=\"via\" class=\"ref-align-right\">Via:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"via\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text ref-input\" id=\"via\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"via\" \/><\/span>\n\t<\/p>\n\t<p><label for=\"sent-date\" class=\"ref-align-right\">Date:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sent-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date ref-input\" id=\"sent-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"sent-date\" \/><\/span>\n\t<\/p>\n<\/div>\n<p><strong>Periodontal examination scheduled for:<\/strong>\n<\/p>\n<div class=\"ref-row ref-three-cols\">\n\t<p><label for=\"exam-day\">Day:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"exam-day\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text ref-input\" id=\"exam-day\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"exam-day\" \/><\/span>\n\t<\/p>\n\t<p><label for=\"exam-date\">Date:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"exam-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date ref-input\" id=\"exam-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"exam-date\" \/><\/span>\n\t<\/p>\n\t<p><label for=\"exam-time\">Time:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"exam-time\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text ref-input\" id=\"exam-time\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"exam-time\" \/><\/span>\n\t<\/p>\n<\/div>\n<h3>CHIEF CONCERNS\n<\/h3>\n<div class=\"chief-concerns\">\n\t<div class=\"cc-column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Periodontal Disease\" \/><span class=\"wpcf7-list-item-label\">Periodontal Disease<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Gingival Hyperplasia\" \/><span class=\"wpcf7-list-item-label\">Gingival Hyperplasia<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<div class=\"no-pad row flex\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Crown Lengthening\" \/><span class=\"wpcf7-list-item-label\">Crown Lengthening<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"crown-tooth\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text cc-inline\" aria-invalid=\"false\" placeholder=\"Tooth #\" value=\"\" type=\"text\" name=\"crown-tooth\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Inadequate Zone of Attached Gingiva\" \/><span class=\"wpcf7-list-item-label\">Inadequate Zone of Attached Gingiva<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Root Coverage\" \/><span class=\"wpcf7-list-item-label\">Root Coverage<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span><br \/>\nOther: <span class=\"wpcf7-form-control-wrap\" data-name=\"other-concern\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text cc-inline\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-concern\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"cc-column\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Ridge Augmentation\" \/><span class=\"wpcf7-list-item-label\">Ridge Augmentation<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Gummy Smile or Uneven Gumline\" \/><span class=\"wpcf7-list-item-label\">Gummy Smile or Uneven Gumline<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<div class=\"no-pad row flex\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Localized Bone Loss\" \/><span class=\"wpcf7-list-item-label\">Localized Bone Loss<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"bone-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text cc-inline\" aria-invalid=\"false\" placeholder=\"Area..\" value=\"\" type=\"text\" name=\"bone-location\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Implant Consultation\" \/><span class=\"wpcf7-list-item-label\">Implant Consultation<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cc-opts\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cc-opts[]\" value=\"Peri-implantitis\" \/><span class=\"wpcf7-list-item-label\">Peri-implantitis<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"ref-row\">\n\t<p><label for=\"comments\">Comments\/details are always appreciated:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"comments\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" 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If you have any questions or need assistance, feel free to call us at (503) 476-1521.<\/p>\n","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-16614","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Referrals - Willamette Valley Periodontics - Wilsonville, OR<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.willamettevalleyperiodontics.com\/wilsonville-or\/referrals\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Referrals - Willamette Valley Periodontics - Wilsonville, OR\" \/>\n<meta property=\"og:description\" content=\"Referring Doctors Please fill out the form below to submit it to our office. 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