please email or fax completed form and x-rays …...please email or fax completed form and x-rays...
TRANSCRIPT
Confiden�ality Note: The documents accompanying this facsimile transmission may contain confiden�al informa�on. The informa�on is intended only for the use of the individual or en�ty named above. If you are not the intended recipient, other
person responsible for delivering it to the intended recipient, you are hereby no�fied that any disclosure, copying, distribu�on or use of the informa�on contained in this transmission is strictly PROHIBITED. If you have received this transmission in error, please no�fy the sender immediately by phone or by return email and destroy this transmission along with any a�achments. Thank you.
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T S R Q P O N M L K
A B C D E F G H I J
Right Left
Reason for Referral
Wisdom Teeth Extrac�on Implants All on Four Biopsy Evalua�on Infec�on (I&D) Apicoectomy Expose & Bond Frenectomy Alveoloplasty
PLEASE EMAIL OR FAX COMPLETED FORM AND X-RAYS PRIOR TOCONSULTATION TO [email protected] OR 408-767-6379
PLEASE EMAIL A PANOREX X-RAY WHEN REFERRING PATIENT FOR WISDOM TEETH.PLEASE EMAIL APPROPRIATE X-RAY FOR ALL OTHER REFERRALS. DO NOT EMAIL BITE WING X-RAYS.
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1 Pa�ents who will receive seda�on must have NO FOOD OR DRINK, for at least 6 hours priorto surgery.
You must arrange for someone to drive you home a�er the surgery and DO NOT DRIVE for the remainder of the day. Your driver should accompany you to the office and be present for the dura�on of the procedure.
Any unmarried pa�ent under 18 years of age must be accompanied by a parent or guardian at the �me of surgery (or have wri�en consent from them at the �me of opera�on).
Please wear loose comfortable clothing.
Special Instruc�ons for Same Day Surgery with IV Seda�on
Pa�ent Informa�onPa�ent Name Address
Phone #(s) Email Minors MUST be accompanied by an adult
Referring Doctor Informa�onReferring Doctor Date AddressOffice # Email
2975 Bowers Avenue, Suite 101 Santa Clara, CA 95051 408-715-1380 | bayareawisdomteeth.com
Khurram Shahzad DDS, MDBoard Cer�fied in Oral and Maxillofacial Surgery