Referral - Strong Memorial Hospital

Strong Memorial Hospital

Department of Oral and Maxillofacial Surgery
601 Elmwood Ave., Box 705

Rochester, NY 14642

Tel: 275-5531

https://omfs.urmc.edu

Please email x-rays to omfs@umrc.rochester.edu

Include patient name and date of birth in the subject line

Fax: 585-461-5420
Patient's Information:
Name
DOB
Parent/Guardian name
Primary phone number
Secondary phone number
Reason for referral:
Extraction of teeth:
Consultation for biopsy of lesion:
Surgical Exposure of teeth:
Consultation for placement of implant:
Consultation for pre-prosthetic surgery:
Consultation for bone grafting/augmentation:
Consultation for soft tissue grafting/augmentation:
Consultation for orthognathic surgery:
Consultation for TMJ surgery:
Consultation for other procedures (please be specific):
Referring Doctor's information:
Name
Date

MonthDayYear
Date
Signature

Clear
Tel:
Fax:
Should be Empty: