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(949) 364‐0250

26732 Crown Valley Parkway, Mission Viejo, CA 92691

Oral Surgery Patient Registration

Patient Registration Form

If you’re interested in a consultation with Dr. Salib, you may fill out the Oral Surgery Patient Registration form below to request an appointment.

To schedule an appointment more quickly, we recommend that you call our office directly at (949) 364-0250.

Today's Date:

Patient Information

Patient Name *

Patient Age *

Gender *

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

Email *

Phone *

Desired Appointment Date

Referring Doctor Information

Referred By *

Phone *

Email *

Teeth and/or Treatment Areas(s)

Verify Tooth Numbers *

Edentulous:

Maxilla

Mandible

Procedure(s)

Provisionalization:

Removable

Fixed

Surgical Template: *

Will Be Provided

Not Necessary

Bone Grafting:

Removable

Ridge Augmentation

Sinus Augmentation

Soft Tissue Enhancement:

Width

Height

Both

Radiograph(s) / CT Scan(s)

Please mark the appropriate box:

Please Take

Being Mailed

Given to Patient

None Taken

Special Instructions and/or Comments

Add any other relevant information in the text field below:

Type the characters *

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Dr. Nader Salib