Date: _______________________________________________

Time:________________________________________________

Day:_________________________________________________

Introducing: _____________________________________________________________

Refered by: _____________________________________________________________

Phone: ______-______-________ Fax: _____-______-_______


Special Instructions for Patients Receiving I.V. Sedation & General Anesthesia:

1. It is important that you take nothing by mouth (this includes food, water, soda, coffee, milk, juices, ect.) for a period of eight (8) hours proir to your treatment

2. Wear comfortable clothes with loose fitting sleeves. Do not wear jewelry. remove contact lenses.

3. Make arrangements for someone to drive you home following the surgery and to stay with you on the day of the surgery.

4. Please bring any instructions or x-rays from your refering doctor.

5. You may need to be off from work or school for one or two days after oral facial surgery.

6. Do not drink alcoholic beverages 12 hours prior to surgery appointment.

7. Follow the postoperative instructions that we give you. Have your prescription filled and take as directed.

Right	Left
1 2 3 4 5 6 7 8	9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25	24 23 22 21 20 19 18 17
Deciduous
A B C D E	F G H I J
T S R Q P	O N M L K
Extraction Tooth #____	Incision & Drainage____
Cosmetic Skin Resurfacing____	Apicoectomy____
Expose & Bond____	RPE____
Biopsy____	Frenectomy____
Frenectomy____	Blepharoplasty____
Other_____________________
Consultation:
Facial Surgery____	Orthognathic Evaluation____
TMJ____	Bone Grating____
Oral / Facial Lesion____	Implants____
Extractions____
Radiographs:
Bieng Mailed____	Given to Patient____
Will Bring X-ray____
Remarks or Special Instructions__________________________________________
____________________________________________________________________

Print Name: ________________________________________

Signature:__________________________________________

Date: ____________________

Our office is combated to providing you with the highest quality of care possible. To help us in scheduling your appointment, please remember the following:

1. Unmarried patients under eighteen (18) years of age must be accompanied by a parent or legal guardian at the time of the initial consult.

2. Please bring all pertinent medical information and a list of all medications you are currently taking.