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Patient Referral

 

Patient Information

Patient Name: *

Phone: *

Date Referral Given:

Referring Dentist:

Referred By: *

Email address: *

Office Phone: *

Hygienist to Contact

Specific Areas of Concern:

Select Teeth:
(Permanent Teeth)

Deciduous Teeth

Upper Left

 
 
 
 

 

  A

  B

  C

  D

  E

 

Upper Right

 
 
 
 

 

  F

  G

  H

  I

  J

 

Lower Right

 
 
 
 

 

  K

  L

  M

  N

  O

 

Lower Left

 
 
 
 

 

  P

  Q

  R

  S

  T

 

Consultation/Procedure:

 
 

 

Extraction

Biopsy/Lesion

  Misc:

 

Implant

 
 

 

Restorative Plan:

 
 

 

Single Crown

Bridge

Locators/Denture

 

All-on-Four

Stayplate

Temp Crown

 

Instructions

Radiographs

 
 

 

Please Take

Emailed

Given to Patient

 

Confirmation

 

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Please visit our website at www.placentiaoralsurgery.com

 

Office Hours



Monday
Tuesday
Wednesday
Thursday
Friday		 7:45am-4:30pm
7:45am-4:30pm
8:00am-4:00pm
7:45am-4:30pm
6:45am-2:00pm

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Oral Surgeon Placentia CA | About Placentia Oral Surgery
With our advanced dental and medical technologies, our Placentia oral surgeon provides patients with nothing less than lasting and beautiful results. Call today.
Young Jun DDS MD FACS, 601 E. Yorba Linda Blvd. #9, Placentia, CA 92870 ^ (657) 216-1617 ^ placentiaoralsurgery.com ^ 6/4/2023 ^ Associated Words: oral surgeon Placentia CA ^