Canterbury Oral & Maxillofacial Surgery
Kurt F. Martin, DDS, MD Ronald L. Roholt, DDS, MD Craig E. Miller, DDS
Referring Doctor_________________________________________Person that Scheduled________________________________________
Patient Name_____________________________________________________________________________________________________
Patient Address_________________________________________________City__________________________ZIP__________________ Home Phone________________________________________Work Phone____________________________________________________ Alternate Phone__________________________________ O Male O Female
Date of Birth_______________________________
Is this a former patient? O Yes O No If yes, when?______________________________ last name (s) used______________________________________________________ What are we seeing this patient for? O Tooth extraction # (s)____________________________________________________________
O Implant # ___________________________ O Other____________________________________________________________________ Diagnosis:
O Non-Restorable Tooth O Acute apical periodontitis
O Other _____________________________________________________________________________________________
What are the patient’s symptoms? O asymptomatic
O Other _______________________________________________________________________________________________________
Have you seen the patient for this condition? O Yes
Has there been any treatment performed or medication prescribed? ______________________________________________________
________________________________________________________________________________________________________________ Is this an emergency (STAT) or urgency (see within the week)? O Yes
If yes, please circle if it is STAT or urgent. Other Information:
(If yes, we would ask the referring doctor to prescribe and instruct the patient to take 1 hour before surgery)
History of Chemotherapy or Immunosuppressants? Yes
History of Bisphosphanates? (Fosamax, Actonel, Didronel, Skelid, Boniva, Aredia, Zometa, Reclast, Other __________)
If yes, has the patient been on it over 3 years?
Has the patient had a pano done within the last year? O Yes
If yes, please send a diagnostic copy to our office showing all anatomy clearly. Referring Doctor’s Signature: ______________________________________________________________________________________ PLEASE FAX THIS FORM TO THE ABOVE NUMBER OR IF X-RAYS ARE AVAILABLE PLEASE E-MAIL OR MAIL PRIOR TO THE PATIENTS APPOINTMENT. For Office Use Only
Date Appointed ___________ Consult Date __________________ Consult Time ______________ Dr. Martin / Dr. Roholt / Dr. Miller
Deliverable nr 15: A generic report from participants’ continuous dissemination The continuous dissemination ensured the project transparency and communicated project results during all the stages of the project progress, maintaining the interest of the public in the project during the whole demonstration. This was done by the means of the constantly updated project webpage: www.agroptiga
Publikationen von PD Dr. med. H. Haberl Adolphs N, Klein M, Haberl EJ , Menneking H, Hoffmeister B. Frontofacial advancement by internal distraction devices. A technical modification for the management of craniofacial dysostosis in early childhood. Int J Oral Maxillofac Surg. 2012 Jun;41(6):777-82. Schulz M, Goelz L, Spors B, Haberl H , Thomale UW. Endoscopic treatment of isolated four
Canterbury Oral & Maxillofacial Surgery
Kurt F. Martin, DDS, MD