Riverside Oral Surgery
316 Knollcrest Drive, Redding, CA 96002
530-223-1811

Patient Referral Form

Securely send patient information, clinical notes, and optional records to our office.

1. Patient Information

Date Referred *

Referring Practice Name *

Referring Practice Phone *

Referring Practice Email *

Referring Doctor *

Patient Name *

Date of Birth *

Phone Number *

Imaging Provided

Upload & Attach FMX

CT Scan taken sent by cloud/USB/Disc

Take a new FMX and share it with us

Upload Files

2. Evaluation For

Tooth Removal

Tooth number(s) or notes

Wisdom Teeth

Tooth number(s) or notes

Dental Implants

Tooth number(s) or site

Bone Grafting

Site or notes

Oral Pathology / Biopsy

Location or description

Exposure of Impacted Teeth

Tooth number(s) or notes

Pre-Prosthetic Surgery

Procedure or notes

TMJ / TMD Evaluation

Symptoms or notes

Other

Please describe

Preferred implant system

Nobel Biocare

Straumann

Surgeon's choice

If you need help with this form or want to see if your patient can be seen the same day, please call our office.
530-223-1811

3. Additional Information

Patient Name Validation *