ORAL SURGERY REFERRAL FORM - Dental Website ... SURGERY REFERRAL FORM Patient Name: _____ Phone No: _____ Referring Doctor Name: _____ Phone Address:

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<ul><li><p>ORAL SURGERY REFERRAL FORM </p><p> Patient Name: _____________________________________________ Phone No: __________________ Referring Doctor Name: ______________________________________ Phone No: __________________ Address: _____________________________________________________________________________ Reason for Referral: </p><p>o Surgical Removal of Erupted Tooth o Soft Tissue Impaction Tooth # __________ o Partial Bony Impaction Tooth # __________ o Full Bony Impaction Tooth # __________ o Surgical Removal of Root Tip __________ o Bone Graft o Implants o Removal of Tori UR UL LR LL o Biopsy o Frenectomy o Alveoplasty o Consultation for Cosmetic Surgery </p><p> Teeth to be Extracted </p><p> A B C D E | F G H I J Patients Right 1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16 Patients Left </p><p>_______________________________________________________________ </p><p> 32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17 T S R Q P | O N M L K Does patient require premedication? Yes No Antibiotic used _____________________________________________________________________ Any medical concerns requiring attention ________________________________________________ </p><p>Radiographs o Please take/send copy o Patient will bring copy o I will send / Please return </p><p> Referring Dentists Recommendation: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Referring Dentists signature: _________________________ Date: ______________ </p><p>DoesPatientRequirePremedication: PatientName: ReferringDoctorName: PatientPhoneNo: DoctorPhoneNo: Address: AntibioticUsed: AnyMedicalConcernsRequiringAttention: ReferingDentist'sRecommendation: ReferingDentist'sRecommendation1: SoftTissueImpactionTeethNo: PartialBonyImpactionTeeth1: FullBonyImpactionTeeth1: SurgicalRemovalOfRootTip1: Radiographs_ChkBox1: Radiographs_ChkBox2: Radiographs_ChkBox3: ReasonForReferral_ChkBox1: ReasonForReferral_ChkBox2: ReasonForReferral_ChkBox3: ReasonForReferral_ChkBox4: ReasonForReferral_ChkBox5: ReasonForReferral_ChkBox6: ReasonForReferral_ChkBox7: ReasonForReferral_ChkBox8: ReasonForReferral_ChkBox9: ReasonForReferral_ChkBox10: ReasonForReferral_ChkBox11: ReasonForReferral_ChkBox12: ReasonOfTori_ChkBox1: ReasonOfTori_ChkBox2: ReasonOfTori_ChkBox3: ReasonOfTori_ChkBox4: ReferingDentist'sRecommendation2: Date: </p></li></ul>