Ali Al-Qudsi, DMD

Board-Certified Oral & Maxillofacial Surgeon
Fellow, AAOMS • Diplomate, ABOMS • Diplomate, ADSA

6 E St. Charles Road • Lombard, IL 60148 • (630) 425-2555 • Fax: (630) 425-2554

Oral Surgery Referral Form

Complete this form and submit to refer a patient to Horizon OMS

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Patient Information

Patient Name

Date of Birth

Phone

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Referring Doctor

Doctor Name

Practice Name

Phone

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Tooth Chart

Click tooth number(s) for extraction / implant

Upper (Permanent)

Lower (Permanent)

Upper (Primary / Pediatric)

Lower (Primary / Pediatric)

Selected:

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Reason for Referral

Extraction Bone Grafting Implant Consultation All-on-X / Full Arch Implants Exposure of Impacted Tooth Sinus Lift / Augmentation Oral Pathology / Biopsy TMJ / Facial Pain Corrective Jaw Surgery Facial Trauma Pre-Prosthetic Surgery / Tori Removal Other

Implant to be placed by:

Horizon OMS Referring Doctor

Preferred implant system:

Straumann NeoDent

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Clinical Notes / Special Instructions

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Imaging / X-Rays

Please take required X-rays Sent with patient Will be emailed

Requesting phone call to discuss case

Date

Referral Received!

Thank you for referring your patient to Horizon OMS.
Our team will review the referral and contact the patient to schedule an appointment. If this is an urgent case, please call us directly.

📞 (630) 425-2555 • 📧 Contact@Horizon-OMS.com

AAOMS Fellow • ABOMS Diplomate • ADSA Diplomate

Horizon OMS of Chicago • 6 E St. Charles Road, Lombard, IL 60148 • (630) 425-2555 • horizon-oms.com