Contributing Writer 
Precise Referral Information To Oral Surgeon
Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)
Date
Dr. Oral Surgeon
Address
City, State Zip
re: patient John Doe
Dr. Oral Surgeon:
I have referred John Doe to you for extraction of:
#B, upper right primary first molar
#I, upper left primary first molar
#29, impacted lower right second bicuspid.
Dr. Ortho and I have elected to leave #H and malformed #11 retained for now, so it will maintain the bone for possible future implant when John is grown.
Dr. Ortho has the original panoramic x-ray taken 1/24/10; I have requested a copy be mailed to your office.
You saw John in August 2009 for other extractions under general anesthesia.
Sincerely,
Dr. _______
Copy: Dr. Ortho; Mr & Mrs Parents of John Doe
