830 Oak St.

, Suite 101W • Brockton, MA 02301

Oral & Maxillofacial Surgery, Inc. Tele: 508-586-5445 • Fax: 508-586-1736
www.omscare.com

PATIENT I N FO R M AT I ON:
Today’s Date 03/15/2023
First Name cailey
Last Name Rubin Date of Birth 03/13/2001
Parent / Guardian Name kenneth Rubin
Contact Telephone Contact E-Mail Addresscpr3313@gmail.om
✔Yes o No
Does the patient require antibiotics prior to dental treatment? o
Treatment wisdom teeth

R EF ERRI N G DO C T O R ’S INF OR MAT ION:

Referred By sheryl Rubin Telephone 617 875-7145
E-Mail Address sruby0313@comcast.net

P ROCEDU R E S :
o Extraction (see below) o Exposure o Frenectomy
o Alveoplasty o Hard Tissue o Apicoectomy
o Biopsy o Infection ✔
o Other
o Incision & Drainage o Expose & Bond wisdom teeth
o Lesion Evaluation o Soft Tissue

✔ ✔ ✔ ✔
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K

Please Verify Teeth For Extraction

C ONSULTAT I O N S :
o TMJ o Cleft Lip & Palate o Bone Grafting
o Implants: o Immediate o Delayed o Cosmetic o Other
o Orthognathic Evaluation o Ridge Augmentation
o Pre–Prosthetic o Oral / Facial Lesion
Implants: Surgical Template: Provided by Surgeon

R A DIOG R AP HS O R C L INICA L P H OT OS :
o Being Mailed TO ATTACH X-RAY(S) TO THIS REFERRAL FORM PLEASE SUBMIT THE FORM ABOVE OR BELOW.
o Given To Patient
AFTER THE FORM IS SUBMITTED YOU WILL THEN HAVE THE OPTION TO UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.
o Please Take
o No X–Ray
✔ Attached With This Referral; if X-Rays are attached, what date were they taken
o

C A SE NO T E S :
I need a appoint as soon as you can fit me in

012422 OMS Care • Copyright © 2021 PBHS Inc. • To Re-Order Call (800) 782-4952