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Oral and Maxillofacial Surgery Referral Form University of Illinois at Chicago College of Dentistry Oral Surgery Fax 312 -996-5987 email oralsurgery uic.edu If emergency please call Dental Urgent Care at 312 -996-8636 Date of referral Referred by Office phone/email/fax Patient name/parent for minors Patient phone Patient email Patient INSURANCE information Dentoalveolar surgery Extraction teeth s Please mark teeth to be extracted on diagram Alveoplasty Incision and drainage Apicoectomy Biopsy Expose and bond Frenectomy Dental implants Pathology/Biopsy Orthognathic evaluation TMJ evaluation Cosmetic facial surgery Radiographs Attached to this referral Will send by email oralsurgery uic.edu None available Medical History Negative Significant Special needs Anesthesia Recommendations Local anesthesia IV sedation General anesthesia operating room Indicate facial injury swelling or other findings Other/Comments Person completing this form Signature initials Phone Fax email Note UIC Missed Appointment Policy - 25 fee for missed appointments and only one appointment allowed. Rev. 11/14.

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