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

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

Referring Doctor Information

Teeth and/or Treatment Areas(s)


Radiograph(s) / CT Scan(s)

Special Instructions and/or Comments

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