Referral Page | North Georgia Oral Surgeon

Demographic Information

Patient Information

Patient Name:

Cell Phone Number:

Date of X-Ray:

Please Provide Patient Phone Number So That We May Begin The Concierge Process

Referring Information

Referring Doctor Information

Referring Doctor:

Referring Doctor Phone Number:

Treatment Information

Permanent:

right

left

Deciduous:

right

left

For Implant Requests:

If requesting digital impressions, please specify lab:

• Please note restoration shade in your records for future Rx
• Lab will be instructed to await Rx from restorative doctor
• We will send implant correspondence when implant is ready to be restored.

Would you like us to send coping and analog for traditional impressions? (check one):

Yes

No

Conclusion

Additional Notes / Comments

All patients must have a pre-surgical consultation with Dr. Abtin before scheduling surgery.

Please notify our office 72 hours in advance if you are unable to keep your appointment.

142 Prestige Ln, Suite 100, Dawsonville, GA 30534

Phone/SMS: (706) 969-7664
northgeorgiaoralsurgeon.com

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