919-841-1720
Oral Maxillofacial Surgeons
Kevin Neshat, DDS, MD
Jorge Perez, DMD
William Benzing, DMD
Amandip Kamoh, DDS
Anthony Immediata, DMD
Dr. Samuel Addison, DDS, MD
Alexandra Petraszko, DDS, MD
Bill Konicki, DMD, MD
Board Certified Periodontists
Nathalie Rivero, DMD, MS
Nu Image Surgical Interactive Referral Pad
referring dr.
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date
referring dr. email
referring dr. phone
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patient phone
email
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Wisdom Teeth Removal
Dental Implant(s)
Pathology
Extractions
Socket Preservation
Alveoloplasty
Bone Grafting
Expose & Bond
CT Scan
Complete Exam
Ridge Augmentation
Laser Treatment
Scaling & Root Planing
Crown Lengthening
Soft Tissue Graft
Apico
Pocket Reduction
LANAP (Laser Assisted New Attachment Procedure)
REMARKS OR SPECIAL INSTRUCTIONS
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Patient will contact
Referring dentist to schedule appointment
Appointment (Date & time)
Radiographs
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Date Xray Taken
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