Rochester Specialty Dental

Rochester Specialty Dental
840 University Ave Rochester, NY 14607

585.278.7199

www.rochesterspecialtydental.com
Patient Name
Date

MonthDayYear
Date
Patient Phone
D.O.B
This patient has been requested to call your office for an appointment with

Oral Surgery and Maxillofacial

George Levine DDS, MD

Endodontics

Jeffry Levine, DDS
REASON FOR REFERRAL (include teeth numbers):
Referring Doctor
For patients anticipating general IV sedation or general anesthesia, they are to have nothing to eat or drink 8 hours prior to surgery. Patients must be accompanied by a driver, who must wait in the waiting room until surgery is completed.
Should be Empty: