Referring Doctors

Referral Form

Thank you for trusting your patient with Loudoun Oral and Maxillofacial Surgery. Our experienced oral and maxillofacial surgeons look forward to a fulfilling care partnership. In order to expedite the referral process, we ask that you fill out any pertinent information using our convenient and secure online form. Please contact our offices directly with any questions or unique circumstances.

Referring Doctor:

Date:

 

Patient Name: First

Patient Name: Last

 

Date of Birth:

Sex:

Patient/Guardian:

Contact Telephone Number:

Reason for Referral:

Dental Implants-Placement Evaluation

Third Molars

Extractions

Expose & Bond

Oral Pathology

Other

If other, please explain:

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Tooth Chart:
(Please mark teeth for extraction/implant)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

 

A

B

C

D

E

F

G

H

I

J

T

S

R

Q

P

O

N

M

L

K

Radiographs

To diagnose and treatment plan patients thoroughly, a full mouth (FMX) set of radiographs are required.

Digital Radiograph attached*(JPG, No Bitewings)

Please take Pano or CT Scan

*Click the "Choose File" button below to attach your files.

All Fields Marked with '*' must be completed to submit the form

Submit Secure Form

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Study Clubs

Dr. Andrew Bluhm and Dr. Steve Dorsch founded the Greater Loudoun Study Club in 2004. A sub-chapter of the prestigious Seattle Study Club, the organization is dedicated to excellence in continuing education in our local Loudoun dental community. Its sister organization, the Greater Loudoun Hygiene Study Club, seeks to provide educational and networking opportunities for area dental hygienists.

We invite you to learn more about both Greater Loudoun study clubs by exploring the links below:

• Greater Loudoun Hygiene Study Club
• Greater Loudoun Study Club