Patient Information
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Select Teeth/Procedures Needed
Extraction of the following teeth (select below)   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A B C D E F G H I J K L M N O P Q R S T   images by OpenDental CONFIRM tooth numbers below (separate with commas):
Other Procedures Alveoplasty Biopsy Incision & Drainage Lesion Evaluation Exposure Hard Tissue Infection Expose & Bond Soft Tissue Frenectomy Consultation TMJ Implants Orthognathic Evaluation Pre-Prosthetic Cleft Lip and Palate Cosmetic Other If other, specify: Radiographs - Select - Being mailed Given to patient Please take No X-Ray Will send via email Implants - Select - Zimmer Surgical Template - Select - Provided by restorative dentist Provided by surgeon
Comments Submit Digital Radiograph Image Press the Browse button and locate the image on your hard drive.  JPG preferred.
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