Referral to Oral Surgery Michiana

Patient name*
Phone Number*
Please enter a valid phone number.
Date of Birth*

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

MonthDayYear
Date
Please check the applicable tooth number

1234567891011121314151617181920212223242526272829303132ABCDEFGHIJKLMNOPQRST
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

Cancelof
Today's Date*

MonthDayYear
Date
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
Should be Empty:

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