Palo Alto Oral Surgery: For Doctors Only

DOCTORS: Please use this on-line referral form to request a new patient referral appointment. After submission of this form, please instruct your patient to bring the necessary materials to the appointment.

Scott D. Fross, D.D.S.

703 Welch Road, B5
Palo Alto, Ca 94304
(650) 328-2322

1261 E. Hillsdale Blvd., #9
Foster City, CA 94404
(650) 525-2111

Appointment Information: This time is reserved specifically for you. If by necessity, you must cancel your appointment for surgery, please notify us at least one day in advance.

Date:

Time:

Day:

Introducing:

Referred by:

Telephone:

Instructions for Patients:

You have been referred for specialized care to an Oral and Maxillofacial Surgeon. Our office will make every effort to make your visit with us a comfortable experience. Please assist us by providing the following information at the time of your consultation.

Your surgical referral slip and any X-rays if applicable
A list of medications you are presently taking
If you have medical or dental insurance, bring the necessary completed forms. This will save time and allow us to help you process any claims.

IMPORTANT: All patients under the age of 21 years of age must be accompanied by a parent or guardian at the consultation visit.

A pre-operative consultation and physical examination is mandatory for patients undergoing IV general anesthesia for surgery.
Please alert the office if you have a medical condition that may be of concern prior to surgery (i.e. diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever).
Our office is determined to allay any concerns you may have about your appointment. Please ask us so we may help you.

Please select teeth or area to be treated.

HOLD DOWN CTRL KEY TO MAKE MULTIPLE TOOTH SELECTIONS.
FOR MAC USERS USE COMMAND KEY.

JAW AREA:
TEETH:
TEETH:

CONSULTATION:

TMJ

Othognathic Evaluation

Implants

Pre-Prosthetic

OTHER PROCEDURES: (Please indicate below)

Alveoplasty
Lesion Evaluation
Infection
Expose & Bond
Laser Procedure

Apicoectomy
Frenectomy
Ligation
Hard Tissue
Extraction

Biopsy
Incision & Drainage
Exposure
Soft Tissue

RADIOGRAPHS:

Being Mailed
No X-Ray

Given To Patient
Will Bring

Please Take

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