Referral - Cortland Oral Surgery

Cortland Oral Surgery

Thomas R. SanGiacomo, DMD
102 North Main Street, Cortland, NY 13045
607-753-0011
cortlandoralsurgery.com
PATIENT:
IS REFERRED FOR:

EXTRACTIONSCBCTEXPOSUREIMPLANTSBONE GRAFT / L PRFOther

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
Upper

	32	31	30	29	28	27	26	25	24	23	22	21	20	19	18	17
Lower

DECIDUOUS

	A	B	C	D	E	F	G	H	I	J
Upper

	T	S	R	Q	P	O	N	M	L	K
Lower

REFERRED BY DR:
INSTRUCTIONS:
New Patient Paperwork can be completed prior to your first visit on our website: cortlandoralsurgery.com

Instructions for patients requiring IV Sedation after initial consultation:
1. Nothing to eat or drink 6 hours before appointment.
2. Bring all pills and medications with you.
3. Must bring someone to drive you home.
4. If under 18, must bring legal guardian.
Should be Empty: