Referring Form

We are pleased and excited to announce that we have implemented OurPerioTeam (OPT), an internet-based software to assist us in bridging the communication between you, our valued referral source and our designated teams, as well as how we collectively serve and treat our mutual patients.

Please use your office’s assigned personal login that gives you access to your portal at any time and from anywhere. Do not hesitate to call us if you need any assistance in obtaining a personal login. As a referring office, there is no charge or subscription fees to use this program. If you are a first time user, you can create your own unique ID Login by entering your practice information.

To send a referral online, please go to the link below and enter your login information:

You can also download our referral form below to provide all the information for your patients. Patients can either bring this form to their appointment or you can fax directly to our office at:

  1. (804) 270-2363 - Henrico Office Fax
  2. (804) 302-3063 - Midlothian Office Fax

Benefits of using this OPT program?

  • Secure, Easy to use, Saves time and Adds efficiency
  • You will be able to refer patients quickly and include as many x-rays and photos as you wish
  • Our office will learn of your patient referrals in real time
  • Ability to track patients that neglect to follow through and make an appointment, as well the treatment status of those who do follow up and see the periodontist
  • Two-way secure communication. By logging in to your portal, you can quickly communicate updates to treatment plan or any questions to our doctor and the office
  • No need for a team member to leave their post and call our office to learn the status of referred patients
  • No fees or cost associated for the referring office to use this program