Referral Page | Inland Empire Oral & Maxillofacial Surgeons

Demographic Information

Patient Information

Name

Date of Birth

Parent / Guardian

Contact Phone / Email

Referring Information

Refer To: (If a specific doctor is desired in a location, check the name. Otherwise, the first available appointment will be given)

First Available - Any Location

Rancho Cucamonga

First Available

Christopher Choi, DDS, MD

Danny Kim, DDS

Upland

First Available

Matthew Dudziak, DDS, MD

Robert Hanna, DDS

Bruce Hicke, DDS

Glendora

First Available

Danny Kim, DDS

Robert Hanna, DDS

Redlands

Jeffrey Paxman, DDS

Referring Doctor Information

Referred By

Telephone

Email Address

Procedures

Extraction Information

Extractions

right

left

right

left

Please Verify Teeth for Extraction

Radiographs or Clinical Photos

TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SUBMIT THE FORM USING THE "Complete and Send" BUTTON BELOW.

AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.

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Inland Empire Oral & Maxillofacial Surgeons

Demographic Information

Patient Information

Referring Information

Refer To: (If a specific doctor is desired in a location, check the name. Otherwise, the first available appointment will be given)

Referring Doctor Information

Procedures

Diagnostic Service

Orthodontic Service

Dentoalveolar Service

Maxillofacial Service

Implant Service

Reconstruction

Extraction Information

Extractions

Radiographs or Clinical Photos

Case Notes

Case Notes