Referring Doctors – California

Referring Doctors

Patient Name(Required)

First Last

Patient Phone Number(Required)

Date of Birth(Required)

Single Tooth Implant #

Implant Additional Info

Please Place Implant Only

Please place implant and restore with screw retained crown

Extraction #

Sinus Augmentation #

Bone Graft #

Horizontal Ridge Augmentation #

Implants With Snap On Denture

Implants With Snap On Denture Additional Info

Please place implants only

Please send precision attachments for denture conversion

Please provide immediate denture

Please perform final denture conversion

ALL-ON-X

Patient is interested in sedation

IV - Conscious Sedation

Full Anesthesia

Referring Dentist(Required)

First Last

Phone Number(Required)

Please Email Referral And Any Current X-Rays To: Referrals@Ora4X.com

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Phone

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