Online Referral Form
You may refer patients to our office by filling out our secure online referral form. After you have completed the form, please make sure to press the 'submit' button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it. If you have any questions or concerns, contact us at info@mysummitoralsurgery.com.
Provider Selection
We now have three providers at Summit Oral Surgery. Note that Drs. Charugundla and Best see a wide range of patients for surgery while Dr. Andrianto's practice with us is limited to oral sleep appliances. Please select one of the following options:
Which provider would you like your patient to see?
*
Prashant Charugundla DDS (Board Certified Oral & Maxillofacial Surgeon)
David Best DDS, MD (Board Certified Oral & Maxillofacial Surgeon)
Fransiskus Andrianto DDS (Board Certified Prosthodontist)
First available
Let Summit pick
Patient Demographic Information
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Parent/Guardian (write "NA" if is an adult)
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email (write "NA" if no email)
*
Please Call Patient
Yes
No
Referring Provider Information
Referring Office Name
*
Referring Provider Name
*
First Name
Last Name
Referring Office Email
*
Referring Office Phone Number
*
Format: (000) 000-0000.
Reason For Referral
Consultations/Procedures
*
Extractions (see below)
Tongue Tie
TMD
Jaw Surgery
IV Sedation
Sleep Apnea
Bone Grafting
Soft Tissue Grafting
Expose and Bond
Alveoplasty
Tori Removal
Biopsy
Incision & Drainage
CBCT Scan Only
Other
Extraction Information
Please verify and list teeth accurately
Radiographs or Clinical Photos
All uploaded files are stored in a secure platform
File Upload
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of
Sleep Study Information
If the patient has had a previous sleep study, please provide the following:
Sleep Clinic Name
Sleep Doctor Name
Sleep Clinic Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Any Additional Information
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Submit
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