Mr./Mrs. ____________________________________ was seen today in our practice.
Please evaluate the area/s noted below:
____ Head and Neck Region
____ Lips/Perioral areas
____ Buccal Mucosa
____ Oral Pharyngeal area
____ Floor of the Mouth
____ Head and neck area
Lesion description and history: (measurements, color, consistency, and general impression):
Pertinent drug history:
Pertinent medical history:
____ Digital image is attached.
From the office of:
Phone: _________________________ Fax: ________________________
Please call our office if you have any further questions or need more information.