Embed Size (px)
Citation preview
75 Prospect Street • Rear Building • Huntington, NY
Dear Patient:
Thank you for choosing our office for your oral surgery care. Your Doctor has filled out this referral card so that we mayproperly and efficiently treat you. Please call our office at (631) 421-2471. Our staff is ready to assist you in making yourappointment.
PPLLEEAASSEE BBRRIINNGG AA LLIISSTT OOFF AALLLL MMEEDDIICCAATTIIOONNSS YYOOUU AARREE CCUURRRREENNTTLLYY TTAAKKIINNGG WWHHEENN YYOOUU CCOOMMEE TTOO OOUURR OOFFFFIICCEE..
When making your appointment, please have the following information ready:
• Your dental and medical insurance information• If you are a college student, please bring proof of enrollment• If you are currently taking any blood thinners (ie. coumadin, plavix, or aspirin)• If you are currently taking any medication for osteoporosis or bone cancer• If you need to take any premedication prior to having any dental procedure
If you plan on having IV sedation, please DO NOT eat or drink 6 hours prior to your appointment and you must be accompanied by a driver. We will be happy to discuss all of your anesthesetic options with you.
All minors must be accompanied by a parent or legal guardian.
PLEASE READ BELOW BEFORE YOU MAKE YOUR APPOINTMENT
Huntington Village Implant & Oral Surgeons • Peter H. Pruden, DDS, P.C. and Associates
NEWLOCATION
Huntington Village Implant & Oral SurgeonsPETER H. PRUDEN, DDS*, P.C. and Associates*Diplomate of the American Board of Oral and Maxillofacial Surgery*Fellow of the American Dental Society of Anesthesiology
75 PROSPECT STREET • Rear BuildingHUNTINGTON, NY 11743 Suite 401
631-476-3304 Ans. Svce.631-547-6809 Fax
“Our Goal Is To Provide Outstanding Service To Our Referring Doctors And Their Patients”
Patient’s Name Date
Referred by
Restorative Treatment Planned
Please treat the following:
A) Extractions (Please mark (X) for extraction)
Remarks:
Introducing
Referred by
A) Extractions (indicate teeth below):
Please mark (X) for extraction
Remarks:
Please treat the following:
Root Resection:
Section Bridge between Tooth #
UPPER
LEFTRIGHT
LOWER
B) Apicoectomy: Tooth #
C) Implant Evaluation Tooth #
D) Oral Pathology-Biopsy
E) Orthognathic, Reconstructive or Trauma Surgery
F) Temporomandibular Joint/MPD Evaluation
INSTRUCTIONS TO PATIENT:Patients who are going to have general anesthesia or intravenous sedation should have nothing to eat or drink for six (6) hours before their appointment. A driver should be with the patient. Minors must be accompanied by parent or guardian.
and Tooth #
Date
Retrofilling
B) Implant Evaluationp Please extract tooth # , and appoint for an implant consult.p Patient is missing tooth # , please schedule for an implant consult.
C) Root Resection:Section Bridge between Tooth # and Tooth #D) Apicoectomy: Tooth # RetrofillingE) Oral Pathology BiopsyF) Orthognathic, Reconstructive or Trauma SurgeryG) Radiographs p To be taken by Oral Surgeon p Given to Patient p Being mailed p Being Emailed
INSTRUCTIONS TO PATIENTS: Patients who are going to have general anesthesia or intravenoussedation should have nothing to eat or drink for six (6) hours before their appointment. A driver should bewith the patient. Minors must be accompanied by parent or guardian.
Hunt.Library
To Oyster Bay Main Street (Route 25A) To Kings Park
PETER H. PRUDEN, D.D.S.*, P.C. ROBERT J. MAIORINO, D.D.S.
*Diplomate of the American Board of Oral and Maxillofacial Surgery
177 Main Street • Suite 102 Huntington, NY 11743
631-421-2470 631-547-6809 Fax
631-476-3304 Ans. Svce.
To Oyster Bay Main Street (Route 25A)
Dr. Peter Pruden • Dr. Robert Maiorino 177 Main Street
To Northport
N
W E
S
Wo
od
bu
ry R
oad
Oak
wo
od
Ro
ad
High Street
To Plainview
Northern State Parkway
Long Island Expressway
Jericho Tpke. (Route 25)
Ro
ute
110 S
pri
ng
Str
eet
Par
k A
ven
ue
Exit 40
Exit 49
Exit 42
Exit 51
New
Yor
k A
ve.
Huntington Elks Club
Hechscher Park
Huntington YMCA
Huntington Train Sta.
Walt Whitman Mall
Woo
dbur
y R
oad
Rou
te 1
10
Long Island ExpresswayNorthern State ParkwayJericho Tpke. (Route 25)
Exit 49Exit 51Exit 42
Exit 40
Huntington Train Sta.
Walt Whitman Mall
Oak
woo
dR
oad
High Street
Pro
spec
t S
tree
t
New
Yor
k A
venu
e
TownHall
Park Avenue
Dr.
Pru
den’
sO
ffice
• Prospect Street is a ONE WAY Street South.
• Dr. Pruden’s officeis on the right side of Prospect Street, NNEEXXTT to200 West Carver Street(the West Carver Medical Bldg).
• Dr. Pruden’s officeis in the RREEAARR of the Parking lot.
#75Rear
Building
New
Str
eet
ONE WAY
ON
EW
AY
ON
EW
AY
Gre
en S
tree
tO
NE
WA
Y
West Carver Street
