Valley Oak Oral Surgery Referral Form

JUSTIN NASSIRI, DDS

1111 E Herndon Ave #104 Fresno, CA 93720

Tel: 559-389-0153 Fax: (559) 492-3788

Email: info@valleyoakoralsurgery.com Website: www.valleyoakoralsurgery.com
Appointment Date

MonthDayYear
Date
Time
Todays Date

MonthDayYear
Date
First Name
Last Name
DOB
Phone
Format: (000) 000-0000.
ParentGuardian Name
Insurance
Subscriber ID
Referring Provider Information. Please include your practice name.
Referred by
Phone
Format: (000) 000-0000.
Email
example@example.com
Fax
Reason For Referral:
Comments
Permanent Dentition
Primary Dentition
Supernumerary
Radiographs:
Radiographs:

Cancelof
Patient Instructions

1. Please bring any insurance information with you including medical insurance for biopsies.

2. Patient's under 18 must have a parent/guardian accompany them to their appointment

Special instructions for Patients Undergoing Sedation:

1. Do not eat or drink, including water, at least 8 hours prior to surgery.

2. You must arrange for someone to drive you home after surgery. Driver must accompany you to your surgery appointment.

3. Please take your normal morning medications with a small sip of water on day of surgery unless otherwise directed by your doctor
Should be Empty: