Today's Date
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Month
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Day
Year
Date
Scheduled Surgery Date
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Month
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Day
Year
Date
Patient Name
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Age
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Referring Doctor
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PLEASE PERFORM THE FOLLOWING PROCEDURE(S):
Extraction(s):
Implant(s):
Biopsy:
Surgical Ligation of lmpaction(s):
Other:
DOES THE PATIENT NEED TO BE PREMEDICATED?
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IS THE PATIENT TAKING BLOOD THINNER?
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*Please list medication.
WILL THE SURGERY BE PERFORMED WITH SEDATION?
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If yes, please follow these instructions:
(1) Nothing to eat or drink for 6 (six) hours before surgery.
(2) Arrange for a responsible adult to accompany you and drive you home.
(3) Please wear a short-sleeved shirt.
Referring Doctor - Please use your mouse to sign below:
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Please verify that you are human
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