Referring Dentist Form

To submit information online, fill out the form below:

Date Of Referral:
MM slash DD slash YYYY
Patient Name:*
First
Patient Telephone Number*
Referring Doctor's Name:*
First
Referring Doctor's Email:*
Enter Email Confirm Email
Referring Doctor's Telephone Number:*
*
- Extractions
- Implants (Nobel Biocare, Straumann, Zimmer)
- Infections
- Bone/Soft Tissue Grafting
- Pathology
- Orthodontic Exposure
- Trauma
- Orthognathic Surgery
- TMJ Evaluation
- Nerve Repair
- Alveoloplasty
- Frenectomy
- Apicoetomy
- Cleft Lip and Palate
- Ridge Augmentation
- OSA Consultation
- Full arch permanent dentures, teeth-in-a-day
Place an “✓” on teeth to be extracted
RIGHT
Permanent
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 32
- 31
- 30
- 29
- 28
- 27
- 26
- 25
- 24
- 23
- 22
- 21
- 20
- 19
- 18
- 17
LEFT
RIGHT
Deciduous
- A
- B
- C
- D
- E
- F
- G
- H
- I
- J
- T
- S
- R
- Q
- P
- O
- N
- M
- L
- K
LEFT
Dental Implant Preference (if any):
- Nobel
- Straumann
- Zimmer
- Neodent
- No preference
Radiographs:
- New Panorex Requested
- Panorex will be sent. Upload here or email to [email protected]
Upload the image here
Max. file size: 2 GB.
Comments:
IV Sedation and General Anesthesia Instructions
Do not eat or drink 8 hours prior to scheduled appointment. (includes mints, candy, etc) Bring a responsible adult to drive you home and stay with you the day of surgery.Minors must be accompanied by a parent or legal guardian.

Frontier Oral Surgery & Implant Center
Dr. Tyler Boyd, DDS, MD
7209 Commons Circle, Unit A
Cheyenne, WY 82009

Phone: (307) 514-9233
Fax: 1-800-952-8830

Office Hours

Monday 8am – 4pm
Tuesday 8am – 4pm
Wednesday 8am – 4pm
Thursday 8am – 4pm
Friday 8am – 3pm

Monday 8am – 4pm
Tuesday 8am – 4pm
Wednesday 8am – 4pm
Thursday 8am – 4pm
Friday 8am – 3pm