Online Referral Form

Please fill out the referral form I have attached to this email and fax or email it back to us.  

Referral Drake Perio 2019



In order to best serve your patient, we suggest scheduling them with our office as they are finishing their visit with you. This creates a simple, worry free process for the patient and allows us to offer them the best appointment option.


The referral form is a helpful item for both Dr. Drake and our team. It gives us the opportunity to properly prepare for your patient’s visit with us to ensure that we can offer them a thorough exam. We ask that you fill out all pertinent information on the referral form. If a question does not apply, feel free to skip it. We are grateful that you take the time out of your busy schedule to provide us with this helpful information.


We kindly request that you share any pertinent patient information with us prior to their scheduled visit. This includes the following: Patient Name, Date of Birth, Contact Information (Address and Phone number) and any Insurance Information.

In addition to patient information, we also ask that you share the completed referral form and any radiographs with dates.  A periodontal probe chart is always appreciated. This ensures that we are adequately prepared to care for your patient.

Please use secure email to send your files You can send any information to our email address, [email protected]

Have more questions? Give us a call! 503-385-8821