Appendix B. Oral Cancer Examination Physician Referral

Mr./Ms./Mrs. ____________________________________ was seen in our office for a dental exam. As part of the general appraisal of all patients, we completed an extraoral and intraoral examination.

Our assessment revealed an area we believe warrants further evaluation. Please see the information provided below:

Location:

Description:

____ Digital Image/Radiograph is attached.

____ Clinical Image is attached.

From the office of:

Dr. _________________________________

Address: ____________________________________________________________

Phone number: _______________________

Please call our office if you have any questions or need more information.