Referral Form | PA Oral, Facial & Implant Surgery, LLC

PA Oral, Facial & Implant Surgery, LLC

Referral Form

INSTRUCTIONS

Please fill out the fields of the form below. You may use the tab key to move from field to field. When you have completed the form, click on the SUBMIT button at the bottom of the page to submit the information to us. Prior to submitting the form you will have the option to attach x-ray images, if desired.

Instructions

PATIENT INFORMATION

DATE *
FIRST NAME *
LAST NAME *
DOB *
PARENT/GUARDIAN *
TELEPHONE *
EMAIL

Does the patient require antibiotics prior to treatment? *
Yes No

Instructions

REFERRING DOCTOR INFORMATION

TREATMENT *
REFERRED BY *
TELEPHONE *
EMAIL *

Instructions

OTHER PROCEDURES	CONSULTATION	RADIOGRAPHS/PHOTOS
Extraction (see chart below)	TMJ	Being Mailed
Alveoloplasty	Implants (Immediate)	Given to Patient
Biopsy	Implants (Delayed)	Please Take
Incision and Drainage	Orthognathic Evaluation	No X-Ray
Lesion Evaluation	Pre-Prosthetic	Attached w/ This Referral
Exposure	Cleft Lip and Palate	Attaching X-Ray Images: At the conclusion of this form you will have the option of attaching/uploading x-ray images with your form submission. Your images must be a common image file type: .jpg, .bmp, .tiff, .png, .pdf, .doc/.docx).
Hard Tissue	Cosmetic
Infection	Ridge Augmentation
Expose and Bond	Oral / Facial Lesion
Soft Tissue	Bone Grafting
Frenectomy	Other
Apicoetomy