Doctor Referrals - Spokane Valley, WA & Post Falls, ID

Doctor Referral Form

Teeth Removal Numbering Chart

If your referring patient needs any tooth removal please specify each tooth based on this numbering system shown.

Patient Referral Form

Please fill out form in full

Fields with red asterisk are required. If you are submitting radiographs and the file fields are highlighted in red after submission, please reattach files.

Patient Referral Name

Referring Doctor Name

Check All That Apply

Please Call Liberty Oral Surgery At 509-922-2273 Please Remove The Following Teeth Other

Anesthetic Options

Local Anesthetic IV Sedation General Anesthetic

Check All That Apply

Emergency Evaluation: Facial Pain / Swelling Dental Implant Biopsy TMJ / Facial Pain Evaluation Expose & Bond Orthognathic Surgery Evaluation Frenectomy Cleft Lip And Palate / Craniofacial Disorders Reconstruction

Radiograph Upload

Other Radiograph Options:

Take New Radiograph Mailed Emailed Sent With Patient

Important Notice To Patients: If You Are Considering General Anesthesia Or Sedation, You Must Have Absolutely Nothing To Eat Or Drink, Not Even Water, For At Least 6 Hours Before Your Surgery. Take Routine Daily Medication With A Sip Of Water. Please Bring A List Of Prescribed Medication To Your Appointment

Doctor Referrals - Spokane Valley, WA & Post Falls, ID

Doctor Referral Form

Teeth Removal Numbering Chart

Patient Referral Form

Please fill out form in full

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Post Falls, ID

Spokane, WA

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