info@nioralsurgery.com | www.nioralsurgery.com
LYELL R. HOGG, DDS
CHRISTOPHER KEPROS, DDS
AARON KOTECKI, DDS
Today's Date:
Patient Name:
Patient DOB:
Patient Phone:
Email:
Referring Dentist:
Referring Dentist Email:
Requested Surgery/Consult:
Reason For Referral
Extractions
Dental Implants
Wisdom Teeth Consultation
Impacted
Fully Erupted
Pathology
Other:
PLEASE MARK THE AREA TO BE TREATED
1
2
3
4
5
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7
8
9
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13
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32
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A
B
C
D
E
F
G
H
I
J
T
S
R
Q
P
O
N
M
L
K
Please verify teeth for extraction:
RECENT RADIOGRAPHS
Patient Carrying
Mailed
Emailed
Date Taken:
Please Take X-rays
Upload X-rays:
Upload More X-rays:
SPECIAL NEEDS
Wheelchair
Non-English Speaking
Physical/Mental Disabilities
Requires POA
Does the patient require antibiotic prophylaxis prior to dental procedures?
Yes
No
If YES please include type and dose of antibiotic prescribed
Does this patient take blood thinners?
Yes
No
If YES, which blood thinner:
Is patient on a bisphosphonate?
Yes
No
ADDITIONAL COMMENTS: