Online Referral Dr. Yunus Langha 17440 FM 529, Suite 100 Houston, Texas 77095 (832) 464-7172 PATIENT REFERRAL FORM Patient Name: * Patient Phone Number: * Referring Dentist:* Referring Office:* Referring Date: Procedures Oral Surgery ExtractionsIV SedationAny Special needsOther Permanent Teeth 0102030405060708091011121314151617181920212223242526272829303132 Primary Teeth ABCDEFGHIJKLMNOPQRST Attachments (Optional) Comments
