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. _______