Colorado West Oral & Maxillofacial Surgery
REFERRAL FORM
D. Cameron Reece, DMD, MD
Jesse L. Gray, DDS, MD
(970) 245-2222
Fax (970) 243-1973
PATIENT INFORMATION
Date
/
Month
/
Day
Year
Date
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Contact Phone
Format: (000) 000-0000.
Email Address
example@example.com
**Please have your patient call our office to schedule at their convenience
Does the patient require antibiotic phophylaxis prior to dental treatment?
Yes
No
Is the patient currently on a blood thinner or Aspirin regimen?
Yes
No
REFERRING DOCTOR'S INFORMATION
Referred By
PLEASE EVALUATE FOR THE FOLLOWING TREATMENT
Wisdom Teeth
Bone Grafting
Biopsy/Lesion Evaluation
Orthognathic Evaluation
Extraction(s)
Tori Removal
Soft Tissue Grafting
Cone Beam CT Scan
Implants
Alveoloplasty
Expose & Bond
Other
Please Select Teeth Requiring Treatment (Use the reference image above)
1
2
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Please Select Teeth Requiring Treatment (Use the reference image above)
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
Written Confirmation of Treatment Requested / Restorative Plan / Special Instructions:
*
RADIOGRAPHS OR PHOTOS
PLEASE INCLUDE CAPTURE DATE (S)
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Sent via Email
Given to Patient
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