Dr. Timothy M. Lawrence, DDS, MS, Inc.

Timothy M. Lawrence,

DDS, MS, Inc.
4333 Monroe St., Suite A
Toledo, OH 43606

Phone: 419.473.2707

Hours:
Mon., Tues., Thurs.
8:00 a.m. - 4:30 p.m.
Wed.
8:00 a.m. - 12 Noon
Fri.
8:00 a.m. - 2:00 p.m.

American Coot
(Mud Hen)

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Timothy M. Lawrence :: Referring Doctors

Referral Form

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Downloadable Referral Form (PDF)

Referring Doctor Name:

Best Phone Number to Contact Referring Doctor:

xxx-xxx-xxxx

Today's Date:

xx/xx/xxxx

Patient's Name:

Patient's Phone:

Patient's Email Address:

Reason for Referral: (Please Explain Special Situations in Text Box Below)

Third Molar Evaluation and/or Removal

Dental Implant Consultation

Dental Extractions

Pathology Evaluation and Treatment

Orthodontic Exposure of Impacted Teeth

Expose Only

Expose and Bracket the Impacted
Tooth/Teeth

Expose and Bracket to be Provided
by Orthodontist

Management of Cleft

Pre-Prosthetic Surgery Evaluation

Orthognathic Surgery Evaluation

Special Needs

Specific Instructions:

(Please request specific treatment below. Indicate tooth numbers of missing teeth in the same quadrant as teeth to be extracted to reduce potential confusion. For example: If tooth number 15 is to be removed and there are two remaining molars in the upper left quadrant and no remaining bicuspids, it is important to know if you have charted 14 or 16 as missing.)

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