Patient Referral Form

Oral & Maxillofacial Surgery of Greater Grand Rapids

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Patient Information

We are Referring:

Referring Information



Examination and Consultation for


Referred By Dr.

Special Instructions for Patients

  1. Patients who wish to have intravenous (IV) anesthesia, must be accompanied by a responsible adult and may have nothing to eat or drink (except for prescription medication) for a minimum of 6 hours prior to their appointment.
  2. Minors must be accompanied by their parents or legal guardians for all surgical and consultation appointments.
  3. Please bring dental & medical insurance cards.
  4. Patients 18 years of age or older must bring valid photo ID.
  5. NO personal checks. We accept all major credit cards, cash, cashiers, checks, money orders, and care credit.
  6. Payment is due at time of surgery.

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