SA-OMS Provider Referral Form

This information is HIPAA Secure. Thank you for considering our office for the care of your patients.

Please correct the errors described below.

SA-OMS Referral Site

Please call if you have any concerns or questions. This link is HIPAA secure and encrypted. If I do not answer please leave a voicemail and I will get back to you promptly. Thank You --Dr. Rathburn

325-949-1288

Patients first and last name

Date of Birth

Contact Telephone

Contact Email address

Date

Treatment Requested

Please specify numbers or letters of teeth to be extracted here. If none please place none in box

For verification please attach any tooth charts or paper referral to form to further clarify teeth needing to be extracted. This can be attached below with files. Can also attach any clinic notes deemed necessary from provider.

Restorative plan or Specific areas to address

Checkbox list

Alveoplasty

Biopsy

Incision & Drainage

Lesion Evaluation

Exposure

Frenectomy

specify area

Implants

Delayed Implants

Immediate Implants

Cleft lip and Palate

Ridge Augmentation

Bone Grafting

Implants

Surgical Template

Attachable Files

Radiographs/Clinical Photos

Send Imaging with patient

Fax Imaging

Attach Imaging here(preferred)

Hipaa Secure and Encrypted

Please Take

Radiographs/Clinical Photos

Add file

Please upload a file

Referring Information

Referred by

Telephone

Email address

Your information will be encrypted.

SA-OMS Referral Site

Please call if you have any concerns or questions. This link is HIPAA secure and encrypted. If I do not answer please leave a voicemail and I will get back to you promptly. Thank You --Dr. Rathburn

325-949-1288

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide