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River Forest 708-456-7787
Berwyn 708-484-9011
La Grange 708-579-0488
West Loop 312-201-4141

Oral Surgery Referral

Please fill out the form below and we will contact you with an appointment time. Required fields are marked with asterisks (*).

Patient Information

Patient Name: *

Select Teeth:

Selected Teeth Details:

Reason for Oral Surgery Referral:

  Extraction (designate teeth)

  Implants/Preprosthetics

  Implant Site Preparation

 

  Biopsy

  Orthognathic Surgery Evaluation

  TMJ

 

  Obstructive Sleep Apnea

  3D Cone Beam CT Scan

 

 

  Other/Comments:

River Forest Office

Information for our Patients:

  1. IF GENERAL ANESTHESIA OR IV SEDATION IS DESIRED:
    1. You may not ear or drink anything including water for six hours prior to your appointment.
    2. You must be accompanied at our office by a responsible adult who can remain in the office and drive you home.
    3. Wear loose clothing (short or loose sleeves preferable).
  2. IF YOU TAKE PRESCRIPTION MEDICATIONS:
    1. Take your oral medications as usual (with only sips of water if intravenous anesthesia is anticipated).
    2. Bring your medications or a list of them to your appointment.
  3. Minors must be accompanied by a parent or legal guardian.
  4. If you are unable to keep your appointment, please notify the office as soon as possible.
  5. The surgery fee is due at the time of surgery unless other arrangements have been made.

Referring Dentist:

Name:

Address:

City:

 

State:

Zip Code:

 

Email address: *

Phone:

Fax:

Will Email X-Ray:

Yes No  

 

Will Send X-Ray with Patient:

Yes No  

 

Confirmation

 
 

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Call Cameo Dental Specialists today to schedule an appointment at one of our convenient locations in La Grange, River Forest, Berwyn and West Loop serving the Pilsen, Hinsdale, Westchester, Western Springs, Elmhurst, The Loop, South Loop, West Town, Wicker Park, Bucktown, Logan Square, River North, Humboldt Park, Wrigleyville, Little Village, Cicero and other Chicago communities.

Cameo Dental Specialists provides exceptional dental care with a focus on Endodontics (Root Canals), Periodontics (Dental Implants), and Oral Surgery to the Chicago communities.

River Forest
7603 West North Avenue
River Forest, Illinois 60305

708-456-7787
More on River Forest location Request an appointment
at River Forest

Berwyn
3116 Oak Park Avenue
Berwyn, Illinois 60402

708-484-9011
More on Berwyn location Request an appointment
at Berwyn

La Grange
475 West 55th Street, Suite 208
La Grange, IL 60525

708-579-0488
More on La Grange location Request an appointment
at La Grange

West Loop
910 W. Van Buren Suite 600
Chicago, IL 60607

312-201-4141
More on West Loop location Request an appointment
at West Loop

The Cameo doctors who lead our experienced and highly trained staff provide exceptional care in a friendly and comfortable environment.
Call Cameo Dental Specialists today to schedule an appointment at one of our locations in Chicago, Berwyn, River Forest and La Grange, IL.


7603 West North Avenue
River Forest, Illinois 60305
708-456-7787
3116 Oak Park Avenue
Berwyn, Illinois 60402
708-484-9011
475 West 55th Street, Suite 208
La Grange, Illinois 60525
708-579-0488
910 W. Van Buren Suite 600
Chicago, Illinois 60607
312-201-4141

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