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Oral Surgery Validation
This simple form will enable you to tell us your choices about your oral surgery referral - it will take no more than 2 minutes to complete.
6
Questions
START
HIPAA
Compliance
1
Your referral reference - please enter carefully
*
This field is required.
This will be provided on your letter - something like ESX0001234. If you arrived here from a text message - this will be completed for you
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2
Do you still need your appointment?
YES
NO
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3
Is this because
I have already had my treatment
I no longer need treatment
My own dentist provided the treatment
Other
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4
Tell us your experience of the treatment you received
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5
If possible, would you like us to change your provider to one who may be able to see you sooner?
YES
NO
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6
Are you happy for us to contact you by text message if we need to?
YES
NO
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