info@nioralsurgery.com | www.nioralsurgery.com
LYELL R. HOGG, DDS
CHRISTOPHER KEPROS, DDS
AARON KOTECKI, DDS
 Today's Date:
 
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Patient DOB:
 
 
 

Reason For Referral

 
 
 

      
 

 

 

PLEASE MARK THE AREA TO BE TREATED

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 Please verify teeth for extraction: 
 

RECENT RADIOGRAPHS


     

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Upload X-rays:


​​​​​​SPECIAL NEEDS

Does the patient require antibiotic prophylaxis prior to dental procedures?    

Does this patient take blood thinners?   
If YES, which blood thinner:
Is patient on a bisphosphonate?  


ADDITIONAL COMMENTS: