Step 1 of 333%Today's Date* Patient's Name* First Last Patient's Phone*Referred By: Name* First Last Referred By: Phone*Referred By: Email* X-Rays Sent by Mail Sent via Email Given to Patient Take X-Ray Attach to this formUpload X-Ray(s) Drop files here or Reason for Referral?Select Teeth to Be Extracted - Upper Arch A B C D E F G H I JRightLeftSelect Teeth to Be Extracted - Lower Arch T S R Q P O N M L KPlease Verify Teeth for ExtractionSpecial Instructions