ORAL SURGERY AND IMPLANT REFERRAL
Today's Date
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Month
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Day
Year
Date
Patient First Name
Last Name
Recommended Treatment
Please Select
Doc to Consult with KH First
Widsom Teeth Extractions
Other Extractions
Dental Implant(s)
All on X
Bone Graft
Alveoplasty
Biopsy
IV Sedation
Snap On Dentures
Please Evaluate the following teeth or areas (If 3rds, please select 1,16,17,32 in THIS drop down)
Please Select
All Thirds 1, 16 , 17, 32
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32
Additional Teeth (for multiple EXT's and/or Implants)
Please Select
1
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Additional Teeth (for multiple EXT's and/or Implants)
Please Select
1
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5
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3
14
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32
Additional Teeth (for multiple EXT's and/or Implants)
Please Select
1
2
3
4
5
6
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10
11
12
13
14
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16
17
32
Referring Doctor/Office
Please Select
Dr. Shelly Thompson Westerville
Dr. Phil Chahine Hilliard
Dr. Ebsinde Akah Hilliard
Dr. Karishma Patel Hilliard
Dr. Karishma Patel Westerville
Is treatment waiting for KH's approval to be scheduled?
Please Select
Yes
No
Additional Information
Surgery Appointment Date (If applicable)
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Month
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Day
Year
Date
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