The Intraoral and Extraoral Exam
Appendix C. Oral Pathologist/Oral Surgeon Referral Form

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
____ Vestibule
____ Tongue
____ Gingiva
____ Palate
____ 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:
Dr. _________________________________________
Address: ____________________________________________________
Phone: _________________________ Fax: ________________________
Date: ___________________________

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