Referral - Wilson Dental

Wilson Dental
289 Chenango St.
Binghamton, NY 13901
(607) 217-7123 Fax (607) 238-1276

ORAL & MAXILLOFACIAL SURGERY REFERRAL
Introducing:
Daytime Telephone:
Tooth number(s):
Reason for appointment

Wisdom Teeth Removal Extraction Jawbone/Socket Preservation Incision & Drainage Expose & Bond Pre-prosthetic Surgery Periapical Surgery Biopsy/Oral Medicine I.V. Sedation/Anesthesia
Radiographs

X-Rays needed X-Rays emailed or sent X-Rays given to patient Send copies of X-Rays taken
Appointment Information

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Date Hour Minutes AM/PM Option
Additional Comments:
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Date:

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Phone Number

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