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