Referral Page | Greater Atlanta Oral Facial Surgery

Demographic Information

Patient Information

Patient Name:

Cell Phone Number:

Date of X-Ray:

Please Provide Patient Phone Number So That We May Begin The Concierge Process

Referring Information

Referring Doctor Information

Referring Doctor:

Referring Doctor Phone Number:

Location Information

Location:

Buckhead

Cumming

Treatment Information

Permanent:

right

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

left

Deciduous:

right

a	b	c	d	e	f	g	h	i	j
t	s	r	q	p	o	n	m	l	k

left

3rd Molar Evaluation

Yes

Full Arch Solution*

Yes

Implant Evaluation

Yes

Extractions Only

Yes

Expose & Bond

Yes

Pathology Evaluation

Yes

*Full arch solution requires a conference between doctors

For Implant Requests:

If requesting digital impressions, please specify lab:

• Please note restoration shade in your records for future Rx
• Lab will be instructed to await Rx from restorative doctor
• We will send implant correspondence when implant is ready to be restored.

Would you like us to send coping and analog for traditional impressions? (check one):

Yes

Conclusion

Additional Notes / Comments

All patients must have a pre-surgical consultation with Dr. Abtin before scheduling surgery.

Please notify our office 72 hours in advance if you are unable to keep your appointment.

Buckhead

3833 Roswell Rd. NE, Atlanta, GA 30342

Phone/SMS: (404) 689-1152

Cumming

425 Peachtree Parkway, Cumming, GA 30041

Phone/SMS: (404) 383-9433