Referral Form

We are a referral-based practice and request referrals and X-rays when scheduling new patients. Referral Form

All new patients will need to provide the following information when scheduling:

1. Demographic information
2. Insurance information (medical and dental insurance)
3. Some medical history (such as taking medications like a blood thinner or if they pre-medicate with antibiotics before dentist visits)
4. If they are okay with local anesthesia or would prefer general sedation for the procedure.
5. When possible, we request patients fill out our Lakes Region Oral Surgery Registration prior to coming in for their initial visit.