Oral Surgery Referral Form

Oral Surgery Referral Form
Date of Referral:

MonthDayYear
Date
Preferred Location for Service:
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Patient Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address:
example@example.com
Responsible Party Name (If patient is underage of 18)

First NameLast Name
Responsible Party DOB

MonthDayYear
Date
RP Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
RP Email Address:
example@example.com
Referred by:
Referred Clinic Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Email Address:
example@example.com
Reason for Referral:
Comments:
Referral form:

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XRAYS and CT Scans or Relevant Files

DCM Files, jpeg, obj
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Date of Image:

MonthDayYear
Date
Tips for exporting a CBCT scan, to drag and drop:

1.       Export the CBCT from your imaging software (DICOM files only) and save it into a desktop folder.

2.       Then right click on the folder, send to, compressed zip folder.

3.       After it is zipped, drag and drop the zip file into the portal.
Copy of Patient's Health/Dental Insurance:

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Referrer's Signature:
Should be Empty: