275 N. Main St., Suite B, Troutman, NC 28166 704-980-4301

referral

Patient Name
Referred by Dr.
MM slash DD slash YYYY

Please indicate teeth to be removed by their names in addition to the chart.

Upper Right
Lower Right
Upper Left
Lower Left

IF THE PATIENT ONLY HAS TWO MOLARS REMAINING, PLEASE INDICATE THE ANTERIOR OR POSTERIOR TOOTH SLATED FOR REMOVAL.

OTHER PROCEDURES - PLEASE INDICATE

Biopsy
Frenectomy
Tori
Endo (Single Canals)
I & D
Alveoloplasty

CONSULTATIONS AND DIAGNOSTIC WORKUP

Ridge Augmentation
Osseointegrated Implants
Orthognathic Surgery