Colorado Springs, CO Oral Surgeons | Colorado Surgical Clinic
Bradley W. Renehan, DDS, MD
640 Southpointe Ct. Suite 150
Colorado Springs, CO 80906
Office: (719) 540-6350 Fax: (719) 527-9487
email: records@
Patient Name: _______________________________ Age: ____ DOB: ___________ Patient Telephone Number: _______________________
Consultation:
□ Third Molars □ Bone Graft □ Exposure / Bracket □ TMJ
□ Extractions □ Alveoplasty □ Sleep Apnea / Snoring □ Implants
□ Apicoectomy □ Orthognathic Surg □ Soft Tissue / Pathology
□ Other: ______________________________________________________________________
Procedure:
□ Third Molars □ Biopsy □ Extractions
□ Implants □ Incision / Drainage □ Alveoplasty
□ Other: _____________________________________________________________________
Radiographs:
□ Patient to bring □ Being mailed/emailed □ Please obtain
□ Please return □ Keep
Remarks: _____________________________________________________________________ ______________________________________________________________________________
Significant Past Medical History: _______________________________________________
______________________________________________________________________________
Dentist’s Name: __________________________________________________ (Please Print)
Dentist’s Signature: _________________________________________ Date: _____________
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NOTE: Indicate teeth to be evaluated/treated with a circle. Indicate missing teeth with X
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