Contributing Writer 
Referral To Oral Surgeon
Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)
Oral Surgery Clinic
Address
City, State Zip
RE: Jane Doe referral
Dear Doctors:
I have referred Jane Doe (dob May 8, 1948) to you for extractions of:
- upper teeth #3, 12, 13, 14;
- all remaining lower teeth (18, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31);
- insertion of lower immediate denture (upper partial will be started after healing).
Enclosed is a panelipse x-ray taken 7/29/2010.
I will see her for initial denture occlusion adjustment immediately after you do her extractions.
The lower immediate denture will be delivered to your office prior to her appointment.
Sincerely,
Dr. _______
