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:

__ Lips/Perioral area __ Gingiva
__ Labial Mucosa __ Palate Anterior
__ Buccal Mucosa __ Palate Posterior
__ Vestibule __ Tongue Dorsum
__ Tongue Lateral __ Retromolar Trigone
__ Tongue Ventral __ Oropharynx and Tonsil Region
__ Floor of the Mouth  

 

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.

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