Referring Dentists and Dental Offices

Please submit the following information to our office. Any radiographs can be sent with the patient or emailed to our office at info@avieoralsurgery.com

We will reach out to the patient to schedule an appointment as soon as possible. Thank you very much!

Referral Request

Avie Oral Surgery Group

Dr. Edna Buckle

1215 Annapolis Road Suite 205
Odenton, MD, 21113
United States

443-741-0696

Patient Name

Name of Patient to be Seen

First Name

Last Name

Phone

A good phone number where we can reach the patient

(###)

###

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Referring Dental Office and Doctor Name

Teeth/Area to be evaluated

Primary or permanent teeth or both.

Reason for the Referral

Services to be Performed

Additional Comments

Any specific instructions