Referral Form

Please correct the errors described below.
  • GREGORY R. ERENA, D.M.D.
  • GILMAN P. PETERSON, D.M.D., M.D.
  • W. MICHAEL SEXTON, D.M.D., M.D.

Please check appropriate office.

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  • Lexington, KY 40517
  • 859-268-4423 or 800-544-4206
  • Fax 859-268-0010
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  • Cynthiana, KY 41031
  • 800-544-4206
  • 859-234-2300

Instructions to Patients:

You have been referred for specialized care to an Oral and Maxillofacial Surgeon. Our office will make every effort to ensure that your visit with us is a comfortable experience. Please assist us by providing the following information at the time of your consultation:

  • This surgical referral slip and any X-rays if applicable.
  • A list of medications you are presently taking.
  • If you have medical or dental insurance, please bring your insurance card(s) with you. This will save time and allow us to help verify benefits and process any claims.

IMPORTANT: All patients under 18 years of age must be accompanied by a parent or guardian at the consultation visit.

  • A pre-operative consultation is mandatory for patients undergoing IV sedation or general anesthesia for surgery
  • Please alert the office if you have a medical condition that may be of concern prior to surgery (i.e. diabetes, high blood pressure, artificial heart valves or joints, rheumatic fever).
  • Our office is committed to allaying any concerns you may have about your appointment. Please ask so we may help you.

PROCEDURES (please indicate)

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