Canterbury Oral & Maxillofacial Surgery
Kurt F. Martin, DDS, MD Ronald L. Roholt, DDS, MD Craig E. Miller, DDS
Referring Doctor_________________________________________Person that Scheduled________________________________________
Patient Name_____________________________________________________________________________________________________
Patient Address_________________________________________________City__________________________ZIP__________________ Home Phone________________________________________Work Phone____________________________________________________ Alternate Phone__________________________________ O Male O Female
Date of Birth_______________________________
Is this a former patient? O Yes O No If yes, when?______________________________ last name (s) used______________________________________________________ What are we seeing this patient for? O Tooth extraction # (s)____________________________________________________________
O Implant # ___________________________ O Other____________________________________________________________________ Diagnosis:
O Non-Restorable Tooth O Acute apical periodontitis
O Other _____________________________________________________________________________________________
What are the patient’s symptoms? O asymptomatic
O Other _______________________________________________________________________________________________________
Have you seen the patient for this condition? O Yes
Has there been any treatment performed or medication prescribed? ______________________________________________________
________________________________________________________________________________________________________________ Is this an emergency (STAT) or urgency (see within the week)? O Yes
If yes, please circle if it is STAT or urgent. Other Information:
(If yes, we would ask the referring doctor to prescribe and instruct the patient to take 1 hour before surgery)
History of Chemotherapy or Immunosuppressants? Yes
History of Bisphosphanates? (Fosamax, Actonel, Didronel, Skelid, Boniva, Aredia, Zometa, Reclast, Other __________)
If yes, has the patient been on it over 3 years?
Has the patient had a pano done within the last year? O Yes
If yes, please send a diagnostic copy to our office showing all anatomy clearly. Referring Doctor’s Signature: ______________________________________________________________________________________ PLEASE FAX THIS FORM TO THE ABOVE NUMBER OR IF X-RAYS ARE AVAILABLE PLEASE E-MAIL OR MAIL PRIOR TO THE PATIENTS APPOINTMENT. For Office Use Only
Date Appointed ___________ Consult Date __________________ Consult Time ______________ Dr. Martin / Dr. Roholt / Dr. Miller
the routine evaluation limits in section will illuminate solid blue for 5 seconds warranties to the purchaser, but Brookstone, in so far as permitted by law, provides these Brookstone® warrants this product against products “as is.” This warranty does not apply to: defects in materials and/or workmanship under a) damage caused by failure to follow instructions • Make sure the speake
L’incontinence urinaire est la perte d’urine involontaire. C’est un problème fréquent, avec un impact important sur l’hygiène et la qualité de vie. Elle peut s’expliquer par différents mécanismes: hyperactivité vésicale, diminution de la contractilité vésicale, hyperactivité sphinctérienne et/ou du périnée, déficience sphinctérienne et/ou du périnée. On distingue
Canterbury Oral & Maxillofacial Surgery
Kurt F. Martin, DDS, MD