Referring Doctors

First Name*

Last name*

Date of Birth*

Parent / Guardian*

Contact Telephone*

Your email*

Does the patient require antibiotics prior to dental treatment?*

Yes

No

Please call patient*

Yes

No

Treatment*

Referred By*

Referral's Phone Number*

Referral Email*

Alveoloplasty*

Yes

No

Apicoectomy*

Yes

No

Biopsy*

Yes

No

If Yes, Where*

Bone Grafting / Ridge Augmentation*

Yes

No

If yes, where*

Cosmetic Surgery*

Yes

No

Exposure (see tooth chart below)*

Yes

No

Expose & Bond for Ortho. (see tooth chart below)*

Yes

No

Extraction(s) (see tooth chart below)*

Yes

No

Frenectomy*

Yes

No

Implants (see tooth chart below)*

Yes

No

Incision & Drainage

Yes

No

Oral / Facial Trauma*

Yes

No

Orthognathic Evaluation*

Yes

No

Sinus Lift*

Yes

No

TMJ*

Yes

No

Wisdom Teeth (see tooth chart below)*

Yes

No

Other:*

Yes

No

Note: For Patients Desiring IV Anesthesia:

The safe use of IV anesthesia requires that patients not eat or drink anything, including water, for at least eight (8) hours prior to the time of surgery. On the day of surgery, patients should take their normal medications per the prescribing physician's instructions with a minimal amount of water. Also, patients must bring a responsible adult driver who will remain in the office during the entire procedure.

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Referring Doctors

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My Best Facial Design

Developed by EDW Marketing

Contact us to schedule a consultation