Boise Office
3003 W Main, Ste 130
Boise, ID 83702
(208) 342-7610

Wood River Office
304 N Main St
Hailey, ID 83333
(208) 788-5308

Star Office 11575 W State St
Star, ID 83669
(208) 286-7755

Twin Falls Office
1411 Falls Ave E
Twin Falls, ID 83301
(208) 537-3700

Whitewater Oral Surgery Group Provider Referral Form

INSTRUCTIONS

Date

Date of Birth

Parent/Guardian

Phone Number

Does the patient require antibiotics prior to dental treatment?

Contacting the patient

Patient will call for appointment

Please call patient

What treatment is required?

Office Location

Referring Doctor Information

Phone Number

Procedures

Consultation

Implant

Immediate

Delayed

Surgical Template

Provided by Restorative Dentist

Provided by Surgeon

Radiographs and/or Clinical Photos

Being Mailed

Given to Patient

Please Take

No X-ray

Attached with this Referral

What date where the attached X-rays taken?

Extractions

Please verify teeth for extraction.

Case Notes

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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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X-ray Upload File(s)

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