Patient Information:
First Name: Last Name: Phone: - -
Date of Birth:

Referring Doctor Information:
Referred By: Phone: - - Email:

Extractions:
Right
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
                               
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Left
Right
A
B
C
D
E
F
G
H
I
J
                   
T
S
R
Q
P
O
N
M
L
K
Left
Please verify teeth for extraction:

Other Procedures:
Alveoloplasty
Biopsy
Incision and Drainage
Lesion Evaluation
Exposure
Hard Tissue
Infection
Expose and Bond
Soft Tissue
Frenectomy

Consultation:
TMJ
Implants
Orthognathic Evaluation
Pre-Prosthetic
Cleft Lip and Palate
Cosmetic
Other:
Implants: Surgical Template:

Radiographs Or Clinical Photos:
Date PANO taken:
Being Mailed
Given to Patient
Please Take
No X-Ray
Comments:
X-Ray Upload:
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5.