Referral Form

Dental Referral Form

www.greatermichiganoralsurgeons.com

Locations:

Flint Office 5417 Gateway Centre Blvd Flint, MI 48507	Tel: (810) 424-0705 Fax:(810) 424-0750
Saginaw Office 5150 Cardinal Square Blvd Saginaw, MI 4860	Tel: (989) 401-6591 Fax:(989) 401-6596
Bay City Office 4161 Shrestha Dr Bay City, MI 48706	Tel: (989) 892-9341 Fax:(989) 778-1719

Owosso Office 306 N Gould St Owosso, MI 48867	Tel: (989) 723-3882 Fax:(989) 723-9882
Oxford Office 113 N Washington St Oxford, MI 48371	Tel: (248) 969-9500 Fax:(248) 969-9509
Midland Office 5220 Eastman Ave Midland, MI 48640	Tel: (989) 874-3500 Fax:(989) 259-7903

Please advise that Patients under the age of 18 MUST be accompanied by a parent or legal guardian
Patient and Referral Information
Appointment Date

MonthDayYear
Appointment Time
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Sex:*

MaleFemale
Patient Phone Number:*
Please enter a valid phone number.
Referring Doctor Email:*
example@example.com
Referring Doctor Name:*
Patient Email:
example@example.com
Pertinent History
Location and Doctors
Select a Location(s)*

Flint OfficeSaginaw OfficeBay City OfficeOwosso OfficeOxford OfficeMidland Office
Select a Doctor(s)*

Michael S. Frey, DDSRobert C. Lesneski, DDSChristopher P. Kittle, DDSMichael R. Higginbotham, DDS, MDShyam Prasad Aravindaksha, BDS, MDSFrederick J. Thompson, DDSXena Alakailly, DMD, BDSJoshua L. Leal, DDS
Oral Surgery Treatment
Oral Surgery Procedures to be Performed:*

Extraction(s)Pathology (Mark on Diagram Below)Socket PreventionTori RemovalImplantsAlveoloplastySurgical ExposureSupernumerary TeethFrenectomyInfection/Incision and DrainageTraumaCT ScanOther
Implants Location:*
Implants: System Preference*

Zimmer Biomet®Nobel Biocare™Implant Direct™
Teeth # (for extraction)*
Surgical Exposure*

With BracketWithout Bracket
Please Mark Area to be Treated
Additional Comments:
X-Ray / Radiographs
Sending X-Rays to our office?*

YesNo
Date X-Rays were taken*

MonthDayYear
Radiographs*

MailedDelivered by PatientUpload/Attached to ReferralEmail
If Being Mailed, Any Information?*
Attach Images(s) of X-ray*

or please send all pertinent radiographs to our office emails under the Email option
Cancelof
If Emailing Forms, Please Send To:
- Flint Office: flintoffice@michiganos.com
- Saginaw Office: saginawoffice@michiganos.com
- Bay City Office: baycityoffice@michiganos.com
- Owosso Office: owossooffice@michiganos.com
- Oxford Office: oxfordoffice@michiganos.com
- Midland Office: midlandoffice@michiganos.com
Additional Comments:
Referring Doctor's Signature*

Clear
Date Signed*

MonthDayYear
Date
IMPORTANT INSTRUCTIONS TO PATIENTS PLANNING TO BE SEDATED (ASLEEP)
- Do not have anything to eat or drink (not even a sip of water) 6 hours prior to your scheduled surgery time.
- You must have a responsible adult with you who will remain in the office until your treatment is completed.
- Please wear a short-sleeved shirt or blouse to allow the placement of a blood pressure cuff.
- Please remove fingernail polish. If acrylic nails are worn, please remove them from the index and middle fingers of your right hand.
Should be Empty:

Dental Referral Form

Patient and Referral Information

Location and Doctors

Oral Surgery Treatment

X-Ray / Radiographs