Referral to Oral Surgery Michiana

Patient name*
Date of Birth*

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Date
Referring Doctor*
Date of Appointment (if already scheduled)

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Date
Please check the applicable tooth number

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What is this referral for?*

ExtractionDental Implant ConsultationIV SedationBone GraftingOrthognathic EvaluationTemporary Anchorage Device (TAD)Fracture EvaluationExpose/Bond and BracketPathology/BiopsyCrown LengtheningAll-on-XFrenectomyReplacement (Flipper, Essex)Other
Please specify the area where a frenectomy is needed (buccal, labial, lingual, etc.)
Additional comments
*NOTE: Radiographs are required for hard tissue pathology referrals, and intraoral pictures are required for soft tissue pathology referrals
Please upload any applicable radiographs/pictures

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Today's Date*

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Edward C. Collins III, DDS, MS* William L. Hull III, DMD*

*Fellow of American Association of Oral and Maxillofacial Surgery *Diplomate of American Board of Oral and Maxillofacial Surgery
NOTICE: PATIENT MUST BRING THIS REFERRAL FORM TO APPOINTMENT
Should be Empty:

*NOTE: Radiographs are required for hard tissue pathology referrals, and intraoral pictures are required for soft tissue pathology referrals