Referral Page | Oral and Facial Surgery Center of Tallahassee

Date:

Patient Name:

DOB:

Telephone:

Email:

Referring Doctor:

Address:

Telephone:

Does the patient require antibiotic pre-medication?

Yes

No

Radiographs

CBCT

FMX

PA

PANO

Enclosed

Emailed

Please Contact Patient

Patient Will Contact You

Please circle teeth numbers:

right

left

right

left

Reason for Referral:

Consultation

Extractions

Pathology

Dental Implants

Trauma / Reconstructive Surgery

Cosmetic / Laser Surgery

Orthognathic Surgery

Bone Grafting

Cleft Lip & Palate

Craniofacial Surgery

Others

Patient Insurance Information:

Company:

Subscriber:

Group #:

DOB:

Phone Number:

Employer:

ld on Card:

Appointment Information

If the patient has not been contacted by the receiving Doctor's office within 48 hours, they should call the specialist's office directly.

Comments

Reasons for Referral: Wisdom Teeth Extraction/Eval

Your appointment is scheduled:

Name:

PLEASE REVIEW THE FOLLOWING INSTRUCTIONS

Please arrive 15 minutes before your scheduled appointment time.
Please bring a list of all medications you are currently taking.
Please remember to bring this referral and x-rays with you.
Minors must be accompanid by parent or legal guardian.
We understand your time is valuable. Please visit our website www.ofsctallahassee.com to complete and print your new patient paperwork prior to arrival, so we may seat you by your scheduled appointment time.

3330 Capital Oaks Drive
Tallahassee, FL 32308

info@ofsctallahassee.com • (850) 386-4602

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Referral Form

Thank You For The Kind Referral