Referral Form for Collins Oral & Maxillofacial Surgery
PATIENT INFORMATION
Date:
Month
Day
Year
First Name:
Last Name:
Telephone:
REFERRING DOCTOR INFORMATION
Referred By:
Telephone:
Email:
EXTRACTIONS
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COMMENTS
EXTRACTIONS
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G
H
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Please Verify Teeth for Extraction:
OTHER PROCEDURES
Alveoplasty
Biopsy
Incision and Drainage
Lesion Evaluation
Exposure of Impacted Tooth
Hard Tissue Lesion
Infection
Expose and Bond
Soft Tissue
Frenectomy
CONSULTATION
TMJ
Implants
Orthognathic Evaluation
Pre-Prosthetic
Cleft Lip and Palate
Cosmetic
Sleep Apnea
Other:
IMPLANTS
Dentsply
Implant Innovations
ITI
Lifecore
TMI
Branemark
Replace Select
Restore
Other
SURGICAL TEMPLATE
Provided by Restorative Dentist
Provided by Surgeon
RADIOGRAPHS OR CLINICAL PHOTOS
Being Mailed
Given to Patient
Please Take
No X-Ray
COMMENTS
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Copyright © 2005 [Collins Oral & Maxillofacial Surgery]. All rights reserved.
Revised: 12/28/05.