Referral Form

Dental Referral Form

Ivey Oral & Facial Surgery - Dr. Austin Ivey, DDS, MD
Address:

14000 E. Arapahoe Rd., Suite 320

Centennial, CO 80112

Email: referrals@iveyofs.com
Tel: 303-493-1933
Fax: 303-493-1934
Please advise your patient that they may call our office to schedule an appointment, and find out if we are in or out of network with their dental insurance. Please note: TMJ, DENTAL IMPLANT, AND/OR EXPOSE & BOND PATIENTS WILL TYPICALLY NEED A CONE BEAM CT PERFORMED IN OUR OFFICE AT THE TIME OF CONSULTATION.
Patient and Referral Information
Are you a:*

Referring DoctorPatient
Only a referring doctor or doctor's office must submit this form
Patient Name:*

First NameLast Name
Patient Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email:*
example@example.com
Patient Date of Birth:*

MonthDayYear
Date
Sex:*

MaleFemale
Referring Doctor Name:*
Referring Doctor or Practice Email:*
example@example.com
Oral Surgery Treatment
Oral Surgery Procedures to be Performed:*

ExtractionAlveoloplastyApicoectomyIncision and DrainageExpose and BondFrenoplastyTraumaBiopsy SiteTMJ EvaluationDental Implant
Biopsy Site*
Teeth # (for extraction)*
Please Mark (X) Area to be Treated
Additional Notes
Consultation For Implant Surgery

Dental ImplantsBone GraftSinus GraftPRPGuided Tissue Regeneration
Dental Implant, Teeth #*
Bone Graft, Teeth #*
Guided Tissue Regeneration*
Soft Tissue Surgery

AlloDerm graftSubepithelial CT graft
Implant System

BioHorizonsNobel BiocareStraumannAstra3iZimmerBiconImplant DirectI would like this to be a Guided Implant caseOther
Prosthetic Plan

Single unitHybrid dentureFixed partial dentureOverdentureCall me to discuss this case
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Radiographs:

Pano EnclosedBeing MailedPano given to PatientPlease TakePanoI-CAT 3D image
Being Mailed, Information
If Pano is enclosed, what date were they taken?

MonthDayYear
Date
Attach Images(s) of X-ray

or Please send all pertinent radiographs to referrals@iveyofs.com
Cancelof
Additional Comments:
Should be Empty:

Dental Referral Form

Patient and Referral Information

Oral Surgery Treatment