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Date
First Name
Last Name
Date of Birth
Phone Number
Email
Referring Doctor
First Name
Last Name
Phone Number
Email
Office Location
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Alexandria
Procedures
Wisdom Teeth Extraction
Dental Implant Placement
Single/Multiple Extractions
Bone Grafting
Expose and Bond
Oral or Facial Pathology/Infection
Alveoloplasty
Frenectomy
Other
Extractions
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Q
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T
Please verify teeth for extraction.
Special Instructions
Restorative Plan
Radiographs and/or Clinical Photos
X-Rays
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Sent by Mail
Sent via Email
Given to Patient
Take X-Ray
Attached to This Form
X-ray Upload File(s)
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X-ray Upload File(s)
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X-ray Upload File(s)
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X-ray Upload File(s)
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X-ray Upload File(s)
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