* = Required Information
PATIENT INFORMATION
Yes No
Yes No
REFERRING DOCTOR INFORMATION


Extraction (see tooth chart below)
Alveoloplasty
Biopsy
Incision and Drainage
Lesion Evaluation
Exposure
Hard Tissue
Infection
Expose and Bond
Soft Tissue
Frenectomy
Other

Implants
Pre-Prosthetic
Cleft Lip and Palate
Cosmetic
Ridge Augmentation
Oral / Facial Lesion
Bone Grafting
Other

Being Mailed
Given to Patient
Please Take
No X-Ray
+ Add more files

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