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

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Referring Doctor

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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

Implant to be placed by:
Preferred implant system:
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Clinical Notes / Special Instructions

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Imaging / X-Rays

Referral Submitted
Referral Received!
Thank you for referring your patient to Horizon OMS of Chicago. Our team will review the referral and contact the patient to schedule. For urgent cases, please call us directly.
(630) 425-2555 · contact@horizon-oms.com