Desert Ridge Implant & Oral Surgery
Matthew A. DeFelice, D.D.S.
Diplomate American Board of Oral & Maxillofacial Surgery
Diplomate National Dental Board of Anesthesia
5315 E. High Street, Suite #119, Phoenix, AZ 85054
Office: 480.563.3960 Fax: 480.563.3965 Website: drimplantsurgery.com
Please fax or mail a copy of this form to our office and/or give a copy to the patient to bring with them to their appointment.
Thank You!
INTRODUCING: Click here to enter text.
REFERRAL IS THE COURTESY OF: Click here to enter text.
TODAY’S DATE:Click here to enter a date. BIRTHDATE:Click here to enter text.
SEX: M ☐
PATIENT ADDRESS: Click here to enter text.
HOME PHONE: Click here to enter text.
CELL PHONE:Click here to enter text.
Oral Surgery Procedure(s) to be Performed:
☐Extraction/Teeth #’s Click here to enter text.
Should we discuss dental implants with the patient?
☐YES
☐NO
_____________________________________________
☐Alveoloplasty ☐ Apicoectomy ☐ Biopsy
☐ Exposure ☐ Exposure/Bond ☐ Frenectomy
☐ Incision/Drainage ☐ Trauma
☐ Other
Consultation For Reconstructive Surgery
☐ Dental Implants ☐ Cleft lip/Palate Evaluation
☐ Facial Trauma
☐ Orthognathic Evaluation
☐ TMJ Evaluation
Consultation For Facial Surgery
☐ Facial lesion(s) Removal
☐ Botox
☐ Juvederm
☐ Scar Revision
☐ Other
Radiographs
☐ Enclosed ☐ Given to Patient ☐ E-Mailed ☐ Please Create
Doctor’s Comments: Click here to enter text.
F☐
TO OUR VALUED PATIENTS:
Your appointment is a time specially reserved for you. If you cannot
keep your appointment, please inform the office 2 (two) days in advance so the time may be given to another
patient.
INSTRUCTIONS FOR PATIENTS WITH CONSULTATION APPOINTMENTS:
1. If your doctor is sending x-rays, please arrange for them to be here at the time of your appointment.
2.
If you are taking medications of any kind, please bring them with you or prepare a list with the name and
dosage.
INSTRUCTIONS FOR GENERAL ANESTHESIA OR SEDATION:
1. You MUST NOT have anything to eat or drink for at least 6 hours before your surgery. This includes
water and or any other beverage unless directed by your surgeon. Failure to follow these instructions may
result in the rescheduling of your surgery and can compromise your safety.
2. Your escort must remain in the office during your office visit and be able to drive you home after
surgery.
3. Please wear short sleeve and loose fitting blouse or shirt to allow for proper placement of monitors and
venous access. Please do not wear excessive jewelry or necklaces, and refrain from the use of contact
lenses and false eyelashes.
4. If a removable appliance is to be placed on the day of surgery, please bring it with you or make
arrangements to have it delivered to our office prior to surgery.
5.
You should plan to rest at home for the remainder of the day following surgery. An escort should be
available to assist you for at least 6 hours following surgery. You should not drive or operate machinery
for at least 24 hours following surgery or within 24 hours of taking prescription pain medication.
Our office is located on the map below. Our office staff will gladly provide additional directions for your travel to our office.
5315 E. High Street, Suite #119, Phoenix, AZ 85054
Website: drimplantsurgery.com
E-Mail: info@drimplantsurgery.com