hvac, grounds maintenance,steam fitting and some other carpredtry

L

URGERY

ASSOCIATES, P A

www.oralsurgerymaryland.com

www.facebook.com/oralsurgerymaryland

GARY M. EPSTEIN, D.D.S.

BRYAN P. KEEGAN, D.M.D.

PRACTICE LIMITED TO ORAL AND MAXILLOFACIAL SURGERY Diplomates, American Board of Oral and Maxillofacial Surgery q Bel Air South Professional Center

2014 Tollgate Road, Suite 100

Bel Air, Maryland 21015

TEL 410-***-****

FAX 410-***-****

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AiWhite Marsh Health Center

114 Sandpiper Circle, Suite 211

White Marsh, Maryland 21236

TEL 410-***-****

FAX 410-***-****

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PATIENT IS BEING REFERRED FOR:

I. EXTRACTION(S) INDICATED BY THE FOLLOWING NUMBER(S) AND/OR LETTER(S): AVAILABLE RADIOGRAPHS/IMAGES: z/ PANO PAX CONE BEAM CONSULTATION:

WISDOM TEETH BONE/RIDGE GRAFT

IMPLANTS PRE-PROSTHETIC SURGERY

PATHOLOGY/BIOPSY ORTHODONTIC PROCEDURES

TRAUMA/TMD OTHER

III. SPECIAL INSTRUCTIONS

1.) INFORM OUR OFFICE IF YOU ARE ON ANY MEDICATIONS. 2.) MINORS MUST BE ACCOMPANIED BY A PARENT/LEGAL GUARDIAN. GENERAL ANESTHESIA INSTRUCTIONS:

1.) NOTHING TO EAT OR DRINK FROM

MIDNIGHT PRIOR TO YOUR APPOINTMENT.

2.) HAVE A RESPONSIBLE ADULT ESCORT.

3.) WEAR A LOOSE SLEEVED SHIRT AND

REMOVE ALL NAIL POLISH.

4.) CALL THE DAY BEFORE IF COLD OR

FLU SYMPTOMS APPEAR.

COMMENTS:

ONLINE REFERRAL AVAILABLE AT ORALSURGERYMARYLAND.COM

Contact this candidate