CALL US TO SCHEDULE
AN APPOINTMENT TODAY

Main Office # (949) 347-9990

Referral

You may fill out the form below and submit it to us online or print out our referral form by clicking the link at the bottom of this page and bring it with you.
Patient Referral Form

Patient's Name:
Daytime Phone:
Bring X-Ray? YesNo
Appointment Date:
Appointment Time:
Tooth #:

Procedure(s) Referred for:
Extraction(s)AlveoplastyBiopsy/LesionIncision and DrainageImplant(s)Bone GraftingFrenectomyTooth ExposureOrthognathicOther

Consultation(s) Referred for:
Oral Surgery

Check Boxes for the Following Categories:
General Anesthesia/IV*Nitrous Oxide Sedation

*If you are scheduled for IV sedation do not eat or drink anything 8 hours prior to surgery.
Wear loose comfortable clothing and you must be accompanied by a driver.

Referring Doctor:
Telephone:

Download Patient Referral Form
referral

COMPANY INFO

GIVE US A CALL

Tel: (949) 347-9990 Toll Free: (877) 200-4588 Covina: (626) 966-1800 Fax: (949) 347-9991 Covina Fax: (626) 858-1788

OUR LOCATIONS

28202 Cabot Road, Suite 420
Laguna Niguel, CA. 92677

IMPORTANT LINKS


CONNECT WITH US