www.doctorsmileonline.com

Referred for extraction of teeth indicated:

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

Right

A

B

C

D

E

F

G

H

I

J

T

S

R

Q

P

O

N

M

L

K

Left

X-rays

General anesthetic instructions prior to surgery:
(If you are to sleep): Do not eat or drink anything for at least 6 (six) hours before surgery. Make arrangements for someone to drive you home following surgery.

Reason For Referral: