Patient Referral Form


Patient Forms

For general dental practices referring patients to Portland Periodontics, your expert in Portland OR periodontics, please use the fillable form below to introduce your patients to our practice

Fillable Forms Instructions

Portland Periodontics uses Adobe Acrobat products to create fillable forms for your convenience. You are responsible for completing all required fields and submitting a hard copy according to the instructions on the form. Some fields may require a handwritten response including a signature.

To view, complete, and print forms you must have Adobe Reader software installed on your computer. You may download this software free of charge from the Adobe website or click here.
Saving a Form

To save a form to your hard drive or other designated drives, you must view and select the form you would like to save. View the selected form in your Web browser. Select on your toolbar or chose File → Save As from your browser’s top menu. A pop-up box will appear and you must:

  1. Save copy as by using the default form name or deleting that name and choosing another
  2. Save in by choosing the location or drive where you would go to access the form offline. (example: save in: My documents)
  3. Chose a File Type which should be defaulted to Adobe PDF file
  4. Click Save if all information is correct or Cancel if you do not wish to save the file.

Completing a Form

Go to the location or drive (example: My documents) where you saved the form. Select and open the file. Position your cursor at a fill-in area or element you want, then left-click. The blinking cursor indicates that you can begin typing your text at that point. The hand pointer allows you to select a check box or radio button.

Enter the appropriate data in each box or field. To move from one field to the next, press the Tab key. You can also use your cursor to move from field to field.

Some fields limit the maximum number of characters you can enter and may automatically advance to the next field.

Once you have completed your form, save your file copy and print a copy for submission and for your files. (See the form instructions or our main forms Web page for mailing instructions.) The form will automatically save in the same location therefore you will not have to repeat the steps above at Saving a Form.


All of the forms on our Web site have interactive fields so you can fill them in online, and print them for signature(s) and mailing in accordance with the instructions on the form. Below your toolbar, you should see a “Highlight fields” option on the right of your screen. You may then proceed to print the file as usual. Select File → Print.

While it is not necessary to save the completed form to your computer in order to print, it is advisable in order to retrieve a copy in the future. After filling in the form fields, you may go directly to File → Print, and print off a hard copy. If you are still experiencing problems, please call 503-245-0180