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Solar Plaza1801 Solar Drive • Suite 100

Oxnard, CA 93030

805-983-3131clarkandpateloralsurgery.com

Solar Plaza1801 Solar Drive • Suite 100

Oxnard, CA 93030

805-983-3131

dOffice Use Only

Patient Name: _____________________________

Date of Referral: ___________________________

Please indicate by an “X” the teeth to be removed.

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T S R Q P O N M L K

Remarks:

Referring Doctor:

Appointment Date:

Appointment Time:

q Patient will bring radiographs

q Radiographs have been mailed.

q Radiographs have been e-mailed.

q Please take necessary radiographs

Please evaluate the patient for:

q Implants

q TMJ

q Pathology

q CBCT scan

Area: _________________________

Dr. Clark and Dr. Patel are Board Certified by the American Board of Oral and Maxillofacial Surgery and are members of the American Association of Oral and Maxillofacial Surgeons, the American Dental Association, the California Dental Association, and the California Association of Oral and Maxillofacial Surgeons.

William J. Clark, D.D.S., M.D.Dr. Clark earned his undergraduate degree from Stanford University and his dental degree from the UCLA Dental School. He received his medical degree and completed his oral and maxillofacial surgery residency at the University of Florida Medical Center.

Brijesh J. Patel, D.D.S., M.D.Dr. Patel earned his undergraduate degree from University of Illinois at Chicago and his dental degree from Columbia University School of Dental Medicine. He received his medical degree and completed his oral and maxillofacial surgery residency at

Case Western Reserve University School of Medicine.

Oral & Maxillofacial SpecialistsAs oral and maxillofacial surgeons, Dr. Clark and Dr. Patel are specialists within the dental community, and specialize in the following:

• Replacing missing teeth with dental implants

• Removing wisdom teeth and difficult to extract teeth

• Removing lesions within and around the facial region

• Treating temporomandibular joint dysfunction (TMJ)

• Surgically correcting jaw deformities, such as an underbite or a protruding chin

• Providing IV sedation for dental procedures

Dr. Clark and Dr. Patel have had extensive training in providing both intravenous sedation and general anesthesia. Both techniques are a light state of sleep in which the patient is comfortable and unaware of the procedures being performed.

Dr. Clark and Dr. Patel are regularly tested and licensed by the State of California to provide general anesthesia.

Your Initial VisitYour first visit will be a consultation appointment. During this visit, Dr. Clark or Dr. Patel will review your medical history, medications, allergies and treatment options. Please bring the following to your consultation appointment:

• Referral brochure• Medical and Dental insurance information• A list of current medications• A list of your physiciansUnmarried patients under the age of 18 must be accompanied by a parent or legal guardian.

InsuranceOur office will be pleased to assist in submitting your insurance claims. For us to do so in a timely manner, please present your insurance information at your initial visit. Since you are the policy holder, you are primarily responsible for your account. All patient copayments are due at the time treatment is provided.

AppointmentsOur office hours are 8:00 AM to 5:00 PM Monday through Thursday and 8:00 AM to 3:30 PM on Friday.

All visits are taken by appointment. However, we do our best to accommodate emergencies.

Our office personnel strive to provide quality care in a courteous, comfortable and efficient manner. We want your experience with us to be a positive one in a warm and sensitive atmosphere.

Proud members of the following Organizations:

We accept all major PPO’s including: