We would like to thank you for referring someone to our office.  In an effort to provide the best service possible, we ask you to fill out this form as completely as possible.

***This page is undergoing updates! Please temporarily use the following email format for all referrals to Dr. Anna Lu, DMD Oral Surgery until further notice.***

Email: drreferral@drluoralsurgery.com
Subject: Doctor Referral from (Name)

Body: (Copy and Paste the below form text into the email body and fill out as completely as possible)
_________________________
Referring Doctor’s Name:
Office:
Doctor’s Phone Number:
Phone Type: (Office) (Cell) (Other:___)
May we call you with questions?: (Yes) (No)
Doctor Email:

Patient Name:
Patient Gender:
Patient Social Security Number:
Patient Date of Birth:
Patient Phone Number:
Phone Type: (Home) (Cell) (Other:__)
May we call the patient to schedule an appointment?: (Yes) (No)
Are X-rays available?: (Yes) (No) (Please attach to email if yes)

Concerns and Comments:

_________________________