Please print this page and fax the completed form to 405-751-7618.
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Patient Name: _______________________________________________
Referring Dr.: _______________________________________________
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[ ] Extractions
[ ] Other Procedures
(please indicate below)
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Please Circle Teeth to be Treated
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Right
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Permanent
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Left
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1 2 3 4 5 6 7 8
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9 10 11 12 13 14 15 16
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32 31 30 29 28 27 26 25
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24 23 22 21 20 19 18 17
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Right
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Deciduous
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Left
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A B C D E
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F G H I J
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T S R Q P
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O N M L K
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[ ] Alveoloplasty
[ ] Infection
[ ] Expose & Bond
[ ] Frenectomy
[ ] Lesion Evaluation
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[ ] Consultation
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[ ] TMJ
[ ] Implants
[ ] Orthognathic
[ ] Facial Cosmetics
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[ ] Radiographs
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[ ] Being Mailed
[ ] No X-ray
[ ] Given to Patient
[ ] Please Return
[ ] Obtain for our Office
[ ] Panoramic
[ ] Periapical
[ ] Lateral Ceph
[ ] Occlusal
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