Client wanted an updated referral form for other peers to send potential patients to her office.

1. Dr. Faith Oliver Dr. Faith Oliver
North Texas Oral Surgery Center North Texas Oral Surgery Center
ORAL SURGERY REFERRAL FORM ORAL SURGERY REFERRAL FORM
Patient: Patient:
is being referred for the following procedures: is being referred for the following procedures:
Consultation Enucleation of Cyst Consultation Enucleation of Cyst
Nitrous Oxide Implant Consultation Nitrous Oxide Implant Consultation
IV Sedation Implant Placement IV Sedation Implant Placement
Extractions Incision & Drainage Extractions Incision & Drainage
Impactions Excision of Tori
Impactions Excision of Tori
Surgical Exposure Removal of Cyst/Tumor Surgical Exposure Removal of Cyst/Tumor
Frenectomy Trauma (Alveolar Fract., etc.) Frenectomy Trauma (Alveolar Fract., etc.)
Alveoloplasty Remove Hypertrophied Tissue Alveoloplasty Remove Hypertrophied Tissue
Immediate Dent. Other Immediate Dent. Other
Biopsy Biopsy
A B C D E F G H I J A B C D E F G H I J
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 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 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
T S R Q P O N M L K T S R Q P O N M L K
Radiograph Enclosed Please Take Panoramic X‐Ray Radiograph Enclosed Please Take Panoramic X‐Ray
Comments:
Comments:
Referred By Office/Doctor
Dr.’s Phone Referred By Office/Doctor
Dr.’s Phone
North Texas Oral Surgery Center North Texas Oral Surgery Center
Methodist Medical Center Methodist Medical Center
221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208 221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208
Office 214.339.7500 Fax 214.339.7503 Office 214.339.7500 Fax 214.339.7503
(See Reverse Side for Directions) (See Reverse Side for Directions)
Dr. Faith Oliver Dr. Faith Oliver
North Texas Oral Surgery Center North Texas Oral Surgery Center
ORAL SURGERY REFERRAL FORM ORAL SURGERY REFERRAL FORM
Patient: Patient:
is being referred for the following procedures: is being referred for the following procedures:
Consultation Enucleation of Cyst Consultation Enucleation of Cyst
Nitrous Oxide Implant Consultation Nitrous Oxide Implant Consultation
IV Sedation Implant Placement IV Sedation Implant Placement
Extractions Incision & Drainage Extractions Incision & Drainage
Impactions Excision of Tori
Impactions Excision of Tori
Surgical Exposure Removal of Cyst/Tumor Surgical Exposure Removal of Cyst/Tumor
Frenectomy Trauma (Alveolar Fract., etc.) Frenectomy Trauma (Alveolar Fract., etc.)
Alveoloplasty Remove Hypertrophied Tissue Alveoloplasty Remove Hypertrophied Tissue
Immediate Dent. Other Immediate Dent. Other
Biopsy Biopsy
A B C D E F G H I J A B C D E F G H I J
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 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 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
T S R Q P O N M L K T S R Q P O N M L K
Radiograph Enclosed Please Take Panoramic X‐Ray Radiograph Enclosed Please Take Panoramic X‐Ray
Comments:
Comments:
Referred By Office/Doctor
Dr.’s Phone Referred By Office/Doctor
Dr.’s Phone
North Texas Oral Surgery Center North Texas Oral Surgery Center
Methodist Medical Center Methodist Medical Center
221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208 221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208
Office 214.339.7500 Fax 214.339.7503 Office 214.339.7500 Fax 214.339.7503
(See Reverse Side for Directions) (See Reverse Side for Directions)

2. Dr. Faith Oliver Dr. Faith Oliver
North Texas Oral Surgery Center North Texas Oral Surgery Center
North Texas Oral Surgery Center North Texas Oral Surgery Center
Methodist Medical Center Methodist Medical Center
221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208 221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208
Office 214.339.7500 Fax 214.339.7503 Office 214.339.7500 Fax 214.339.7503
Directions & Parking Directions & Parking
We are located in Pavilion 1 at Methodist Hospital in Dallas. Please We are located in Pavilion 1 at Methodist Hospital in Dallas. Please
park in garage A (enter from Colorado Blvd.) park in garage A (enter from Colorado Blvd.)
Once you park, enter the double glass doors and take the elevator to Once you park, enter the double glass doors and take the elevator to
Level E (4th floor). Walk across the sky bridge to Pavilion 1. Take Level E (4th floor). Walk across the sky bridge to Pavilion 1. Take
those elevators to the 2nd floor. We are located to the right when those elevators to the 2nd floor. We are located to the right when
you exit the elevators you exit the elevators
For smart phone users, scan here to get instant directions on your cell! For smart phone users, scan here to get instant directions on your cell!
Dr. Faith Oliver Dr. Faith Oliver
North Texas Oral Surgery Center North Texas Oral Surgery Center
North Texas Oral Surgery Center North Texas Oral Surgery Center
Methodist Medical Center Methodist Medical Center
221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208 221 W. Colorado Blvd., Pavilion I, Suite 222, Dallas, TX 75208
Office 214.339.7500 Fax 214.339.7503 Office 214.339.7500 Fax 214.339.7503
Directions & Parking Directions & Parking
We are located in Pavilion 1 at Methodist Hospital in Dallas. Please We are located in Pavilion 1 at Methodist Hospital in Dallas. Please
park in garage A (enter from Colorado Blvd.) park in garage A (enter from Colorado Blvd.)
Once you park, enter the double glass doors and take the elevator to Once you park, enter the double glass doors and take the elevator to
Level E (4th floor). Walk across the sky bridge to Pavilion 1. Take Level E (4th floor). Walk across the sky bridge to Pavilion 1. Take
those elevators to the 2nd floor. We are located to the right when those elevators to the 2nd floor. We are located to the right when
you exit the elevators you exit the elevators
For smart phone users, scan here to get instant directions on your cell! For smart phone users, scan here to get instant directions on your cell!