INSTRUCTIONS Fill in the fields on the form by using the tab key to move from field to field. When you have completed the form, click on the SUBMIT FORM button at the bottom of the page. Once you submit this form you will have the option to upload up to 5 x-rays images. PATIENT INFORMATION Date: First Name: Last Name: Date of Birth: Parent/Guardian: Telephone: E-Mail: Does the patient require antibiotics prior to dental treatment? YesNo REFERRING DOCTOR INFORMATION Referred By: Telephone: Email: OTHER PROCEDURES CONSULTATION RADIOGRAPHS/CLINICAL PHOTOS Extraction (see tooth chart below) Alveoloplasty Biopsy Incision and Drainage Lesion Evaluation Exposure Hard Tissue Infection Expose and Bond Soft Tissue Frenectomy Apicoetomy Other: TMJ Implants Orthognathic Evaluation Pre-Prosthetic Cleft Lip and Palate Cosmetic Ridge Augmentation Oral / Facial Lesion Bone Grafting Other: IMPLANTS Biomet 3iAstraBioHorizonImplant InnovationsKeystone / LifecoreMiSNobel BioCareStraumannZimmerOther SURGICAL TEMPLATE Provided by Restorative DentistProvided by Surgeon Being Mailed Given to Patient Please Take No X-Ray Upload X-Ray Images: Once you submit this referral form, the confirmation box will give you the option to upload up to 5 x-rays. (must be a common image file type: .jpg, .bmp, .tiff, .png, .pdf, word document). If X-Rays are attached, what date were they taken: EXTRACTIONS RIGHT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 LEFT 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 EXTRACTIONS RIGHT A B C D E F G H I J LEFT T S R Q P O N M L K Please Verify Teeth for Extraction: COMMENTS Once this form is submitted, you will have the option to PRINT a copy of this submitted form in a PDF format.