Appendix C. Oral Pathologist/Oral Surgeon Referral Form

Mr./Mrs./Dr. ______________________________________________ was seen today in our practice.

Age: ____________ If Child, accompanied by: __ Parent __ Grandparent __ Other: __________________

Reason for patient visit:

__ Periodic Recare __ Specific Concern

Please list details:

Please evaluate the specific area(s) noted below for intraoral examination:

Specific concerns for evaluation of head and neck area:

__ Craniofacial/Headache

__ TMJ

__ Upper / Med / Lower Face __ Left __ Right __ Both

__ Midline / Anterior / Lateral Posterior Neck __ Left __ Right __ Both

Level of pain reported by patient: (pain)

Lowest-0 1 2 3 4 5 6 7 8 9 10-Highest

__Location of Pain Perception from above list: ___________________________________________

Specific tooth number of pain association: _________________________________________

Lesion description and history: (measurements, color, consistency, and general impression):

Listed below please find any relevant medication/drug history and/or medical history:

Pertinent medical history:

Pertinent drug history:

____ Digital image of lesion attached.

____ Oral digital or hard copy radiograph of lesion are attached.

____ Digital or hard copy clinical image is attached.

From the office of:

Dr. ______________________________________________________________

Address: __________________________________________________________

Phone: ____________________________ Fax: ___________________________

Date: _____________________________________________________________

Please call our office if you have any further questions or need more information.