Oral Surgery Referral Form for All-In-One Dental Innovations

Demographic Information
Introducing*
Phone*
Referring Doctor*
Phone*
Email: *
Please Evaluate For*

Periodontal Examination and ConsultationSoft Tissue GraftingCrown LengtheningPre or Post-Orthodontic TreatmentExtraction/Ridge PreservationImplantsImplant Site PreparationOther
Reason for Referral*
Other
Tooth #(S):
Have you advised the patient of the possibility of extraction of any teeth?

YesNo
If Yes Which Teeth?
Does the patient require premedication?

YesNo
Antibiotic Used:
Does the patient have pending treatment with your office?

YesNo
Notes
Upload X-Ray Images*

Cancelof
Additonal Follow Up questions:*

Alternate Recare AppointmentsCall Me Before Seeing The PatientCall Me After Seeing The PatientCall Patient To ScheduleDo All Recall Care After Patient Is TreatedSend Me Report
*Note: IV Sedation and General Anesthesia Instructions:
- Do not eat or drink for 8 hours prior to the scheduled appointment.
- Bring a responsible adult with you to drive you home and stay with you the day of surgery.
- Minors must be accompanied by a parent or legal guardian.
Should be Empty: