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A letter on coronavirus awareness from Placentia Oral Surgery

Public Safety and Patient care is our TOP priority.
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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
Our state-of-the-art oral surgery practice is proud to serve patients from the neighboring communities of Anaheim Hills, Yorba Linda, Orange, Brea, and Fullerton.
Young Jun DDS MD FACS, 601 E. Yorba Linda Blvd. #9 Placentia, CA 92870 • (657) 216-1617 • placentiaoralsurgery.com • 8/3/2021 • Key Phrases: oral surgeon Placentia CA • oral surgeon Placentia CA •