Oral Surgery Referral Form for All-In-One Dental Innovations

  • Demographic Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Please Evaluate For*
  • Have you advised the patient of the possibility of extraction of any teeth?
  • Does the patient require premedication?
  • Does the patient have pending treatment with your office?
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  • Additonal Follow Up questions:*

  • *Note: IV Sedation and General Anesthesia Instructions:

    • Do not eat or drink for 8 hours prior to the scheduled appointment.
    • Bring a responsible adult with you to drive you home and stay with you the day of surgery.
    • Minors must be accompanied by a parent or legal guardian.
  • Should be Empty: