Fill The Referral Form

868 Auto Center Drive / Ste A • Palmdale, CA 93551 Phone (661) 208-4280 • Fax (661) 208-4287 www.AVDentalSurgeryCenter.com

We Specialize in Oral Surgery

As well as Periodontics

Doctor-Patient Info:

Appointment Information: This time is reserved specifically for you. If, by necessity, you must reschedule your appointment for surgery, please notify us at least one day in advance.

For Oral Surgery Referrals

Jonathan K. Nakano, DMD

Luiza Portnoff, DDS

Diplomates, American Board of Oral Maxillofacial Surgery

Special Instructions for General Anesthesia Patients:

Patients who receive general anesthesia should not have ANY FOOD OR DRINK, including water, for at least 6 hours prior to surgery.

You must arrange for someone to drive you home after surgery. Your driver must come into the office to pick you up.

Please bring this referral with you to your appointment.

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For Perio Referrals

Alex D. Lopez, DDS

Diplomate, American Board of Periodontology & Dental Implant Surgery

Implant Evaluation For:

Has the patient received quadrant scaling and root planing?

X-RAYS:

Does the patient have a recent FMX you can provide us?