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Referral for Oral Surgery

Presenting

Name

Date of Birth

Date

Patient Phone Number

Radiographs

With patient

Mailed

Emailed

Should we contact the patient to schedule?

Yes

No

Reason for Referral

Extraction / Surgical Removal

Uncovery / Exposure

Apical Surgery

Pathology

Trauma / Facial Fracture

Cleft Palate

Implant Consult

Orthognathic Consult

Comments

1

2

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32

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17

A

B

C

D

E

F

G

H

I

J

T

S

R

Q

P

O

N

M

L

K

Referring Office

Referring Doctor

Office Phone

May we communicate via email?

Yes

No

If yes, email address

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