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Specialty Dental Group - Dentist In Montebello

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Call: (323) 516-6366

Referral Form

Title - Patient Information

PATIENT INFORMATION

Full Name

Date of Birth

Parent / Guardian Full Name

Contact Telephone

Contact E-mail Address

Does the patient require antibiotics prior to dental treatment?

Yes

No

Please call patient

Yes

No

Treatment

Referring Doctor Information

REFERRING DOCTOR INFORMATION

Referred By

Telephone

E-mail Address

Procedures - title

PROCEDURES

Procedures

Extraction (see below)

Alveoplasty

Biopsy

Incision & Drainage

Lesion Evaluation

Exposure

Hard Tissue

Infection

Expose & Bond

Soft Tissue

Frenectomy

Apicoectomy

Other

Other Procedures

Extraction title

EXTRACTION INFORMATION

Upper teeth

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Down teeths

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

teeth letters top

A

B

C

D

E

F

G

H

I

J

teeth letters bottom

T

S

R

Q

P

O

N

M

L

K

Please Verify Teeth for Extraction

Consultations - Title

CONSULTATIONS:

Implants:

Inmediate

Delayed

Consultation

TMJ

Orthognathic Evaluation

Pre-Prosthetic

Cleft Lip and Palate

Cosmetic

Ridge Augmentation

Oral / Facial Lesion

Bone Grafting

Other

other consultations

RADIOGRAPHS OR CLINICAL PHOTOS - TITLE

RADIOGRAPHS OR CLINICAL PHOTOS

Radiographs

Being Mailed

Given to Patient

Please Take

No X-Ray

Attached with this referral

If X-Ray are attached, what date were they taken

Upload file

Upload X-Ray

Case Notes - Title

CASE NOTES

case notes

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709 W Beverly Blvd Suite 101

Montebello CA

90640

(323) 516 6366

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