Referral to Oral Surgery Michiana

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Referring Doctor
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Please check the applicable tooth number
What is this referral for?

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Please specify the area where a frenectomy is needed (buccal, labial, lingual, etc.)
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*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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Edward C. Collins III, DDS, MS* William L. Hull III, DMD* Lane T. Haws, DMD, MD**

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