OMS Referral Form | Keystone Oral Surgery

Prefer to print & fax?

Download the PDF referral form and fax it to (570) 256-1772 or email to contact@keystoneomfs.com.

Referral Form PDF

Appointment Location

Shamokin Dam30 Baldwin Blvd, Suite 95, Shamokin Dam PA 17876

Chambersburg1061 Lincoln Way E, Chambersburg PA 17201

Referring Doctor Information

Referring Doctor Name *

Phone *

Office Address

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Phone *

Patient Address

Insurance Company

Insurance ID #

Reason for Referral

Teeth to be Extracted

Select the tooth/teeth involved in this referral:

Click teeth to select. Selected teeth are highlighted.

PATIENT'S
RIGHT

PATIENT'S
LEFT

Medical Information

Does Patient Require Premedication?

YesNo

Antibiotics Used

Any Medical Concerns Requiring Attention

Radiographs

Radiograph Delivery Method

Please take / send copyPatient will bring copyI will send / Please return

Optionally attach X-rays, panoramic images, periapical films, CBCT scans, or any supporting documents.

Click to upload X-rays or documents

PDF, JPG, PNG, DICOM up to 25MB each

Prefer to print & fax?

Download the PDF referral form and fax it to (570) 256-1772 or email to contact@keystoneomfs.com.

Referral Form PDF

Appointment Location

Shamokin Dam30 Baldwin Blvd, Suite 95, Shamokin Dam PA 17876

Chambersburg1061 Lincoln Way E, Chambersburg PA 17201

Referring Doctor Information

Referring Doctor Name *

Phone *

Office Address

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Phone *

Patient Address

Insurance Company

Insurance ID #

Reason for Referral

Teeth to be Extracted

Select the tooth/teeth involved in this referral:

Click teeth to select. Selected teeth are highlighted.

PATIENT'S
RIGHT

PATIENT'S
LEFT

Medical Information

Does Patient Require Premedication?

YesNo

Antibiotics Used

Any Medical Concerns Requiring Attention

Radiographs

Radiograph Delivery Method

Please take / send copyPatient will bring copyI will send / Please return

Optionally attach X-rays, panoramic images, periapical films, CBCT scans, or any supporting documents.

Click to upload X-rays or documents

PDF, JPG, PNG, DICOM up to 25MB each