Referral Letter (Oral Surgery, Extractions, or Exposure)

Date: [date of referral]

To: [OMS name/practice or "Oral Surgery Team"; address/fax if known]

From: [referring clinician name, credentials, practice, direct phone, secure fax/email]

Patient: [full legal name], DOB: [date of birth], [one additional identifier: phone or MRN] (If any identifier is missing, state "Unknown/Not provided—verify with patient.")

Guardian: [name, relationship, phone] (Include only if minor or dependent adult; otherwise omit entirely.)

Subject: Referral to Oral Surgery – [requested procedure(s)] – [Routine / Urgent] – [patient last, first name]

Referral Request

[Referral intent and reason] (State in one sentence: Procedure Request, Consultation, or Co-management, and the clinical reason for referral.)

[Requested procedure(s) with tooth identification] (List each tooth identified three ways: tooth number, anatomic name, and side/arch—e.g., "#11 = maxillary left canine." Include urgency and any timing constraints. If tooth identifiers are ambiguous or incomplete, note verification is required; do not guess.)

Clinical Summary

Situation: [Current clinical situation and key symptoms prompting referral] (1–2 concise sentences.)

Background: [Relevant dental/medical history impacting surgery or anesthesia; prior related treatments; anesthesia history if relevant] (Include only information material to the surgical request.)

Assessment: [Working diagnosis related to the surgical site(s)] (Include differential only if clinically relevant to surgical planning.)

Exam: [Date examined] — [Pertinent extraoral and intraoral findings at/near surgical site(s)] (If not examined by referrer, state "Not examined by referrer.")

Imaging: [Modality and date(s)] — [Key findings: nerve proximity, adjacent root risk, pathology, spatial orientation, other surgical considerations] (If no imaging available, state "None available." Attach full images/reports separately.)

Medical Considerations

Conditions: [Bleeding/clotting status; diabetes; immune compromise; cardiac/pulmonary disease; OSA; seizure history; antiresorptive/antiangiogenic exposure with agent, dose, and dates if known] (If MRONJ risk factors are unknown, state "MRONJ risk: Unknown/not assessed.")

Medications: [Surgically relevant medications including anticoagulants, antiplatelets, steroids, immunosuppressants, oncology agents, opioids] — [patient-reported / chart-verified]

Allergies: [Drug and reaction type] (If not verified, state "Unknown/not assessed—verify before scheduling." Do not assume none.)

Social history: [Tobacco/vaping; cannabis; alcohol; other substances relevant to anesthesia] (Include only if known and pertinent to surgical/anesthesia planning.)

Orthodontic Coordination

(Include this section only if orthodontic treatment is active; otherwise omit entirely.)

Status: [Current orthodontic phase and rationale for requested surgical procedure]

Exposure/Bonding details: [Technique preference if clinically justified, otherwise request OMS recommendation]; [desired attachment type]; [preferred chain exit location]; [appliance or access constraints]; [anticipated timing to initiate traction]

Post-op coordination: [Request OMS guidance on restrictions or precautions affecting orthodontic forces/scheduling]

Attachments & Closing

Attachments: [List enclosures with type and date: radiographs, CBCT, photos, ceph/tracings, models/scans, medical clearance] (If none, state "No attachments.")

Please send consult note and operative report. Contact me before any scope changes.

Signature: [Name, credentials, practice, direct contact]