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Johnson C Miin DDS Inc
Oral Maxillofacial Surgery and Implants
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Thank you for your referral and confidence in us!
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Today's Date
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Referring Doctor
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Name of Referrring Doctor
Practice Phone Number
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Patient Information
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Name of Patient
Patient Phone #
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Patient Date of Birth
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Additional Medical Concerns
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None, there are no concerns for treatment.
Please indicate any concerns such as blood thinners, bisphosphonate medications and/or medical conditions such as cancer etc
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Reason for Referral
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Decayed, Non-restorable/non-salvageable
In Your Own Words such as: Pain, Infection, Swelling, Periodontal Disease, Bone Loss , Lesion, etc
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Procedure and Location
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Additional Information
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If necessary, please provide additional information for Procedure and/or Location
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Radiographs
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Will Upload Image
To Be Taken At Time of Appointment
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Image Upload
Please Name File with
Name of Patient
and
Date of Image
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Date of Image
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Date
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Signature
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