Referral Form

Information Must Be Filled Out

Instructions for patients :

1. Patients receiving oral sedation must have absolutely nothing to eat or drink 4 hours before appointment time.

2. Minors must be accompanied by a parent or legal guardian, or must have a written consent for treatment and anesthesia.

3. Please bring this card and, if available, recent X-rays of the areas involved.

4. Please give us at least 24 hours notice if you are unable to keep this appointment.

Please fill all the fields.