* = Required Information
PATIENT INFORMATION
Date:
*
First Name:
*
Last Name:
Date of Birth:
*
Telephone:
*
Email:
*
Does the patient require antibiotics prior to dental treatment?
Yes
No
Is the patient currently taking blood thinners?
Yes
No
REFERRING DOCTOR INFORMATION
Referred By:
Telephone:
Email:
OTHER PROCEDURES
Extraction (see tooth chart below)
Alveoloplasty
Biopsy
Incision and Drainage
Lesion Evaluation
Exposure
Hard Tissue
Infection
Expose and Bond
Soft Tissue
Frenectomy
Other
Other
CONSULTATION
Implants
Pre-Prosthetic
Cleft Lip and Palate
Cosmetic
Ridge Augmentation
Oral / Facial Lesion
Bone Grafting
Other
Other
RADIOGRAPHS/CLINICAL PHOTOS
Being Mailed
Given to Patient
Please Take
No X-Ray
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What date were they taken:
EXTRACTIONS
RIGHT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
LEFT
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
EXTRACTIONS
RIGHT
A
B
C
D
E
F
G
H
I
J
LEFT
T
S
R
Q
P
O
N
M
L
K
Please Verify Teeth for Extraction:
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