(406) 655-0170
Get Directions
Instructions
View Menu
Oral Surgery Home
Wisdom Teeth
Dental Implants
Other Services
About Us
Kyle Tracy, DMD
Andrew Boyce, DDS, MS
Stories and Reviews
Pay Now
Resources
Patient Information
Instructions
Referral Form
News
Contact Us
Contact Us – Main Office
Contact Us – Heights Office
Contact Us – Cody, WY
Contact Us – Sheridan, WY
(406) 655-0170
Referral Form
Home
»
Referral Form
Step
1
of
3
33%
Today's Date
*
MM slash DD slash YYYY
Patient's Name
*
First
Last
Patient's Phone
*
Referred By: Name
*
First
Last
Referred By: Phone
*
Referred By: Email
*
X-Rays
Sent by Mail
Sent via Email
Given to Patient
Take X-Ray
Attach to this form
Upload X-Ray(s)
Max. file size: 50 MB.
Max. file size: 50 MB.
Please evaluate for the following treatment(s):
Wisdom Teeth Extraction
Dental Implant Placement
Single/Multiple Extractions
Bone Grafting
Impacted Tooth Exposure
Facial Trauma
Oral or Facial Pathology/Infection
TMJ Disorder
Facial Aesthetics/Cosmetics
Other
Select Teeth to Be Extracted - Upper Arch
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Right
Left
Select Teeth to Be Extracted - Lower Arch
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
Select Teeth to Be Extracted - Upper Arch
A
B
C
D
E
F
G
H
I
J
Right
Left
Select Teeth to Be Extracted - Lower Arch
T
S
R
Q
P
O
N
M
L
K
Please Verify Teeth for Extraction
*
Special Instructions
Restorative Plan
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
Main Office
Billings Oral Surgery
& Dental Implant Center
152 S 32nd St W, Suite B
Billings, MT 59102
Main:
(406) 655-0170
Hours:
Mon–Thu: 8:00 AM–3:45 PM
Fri:
8:00 AM–1:45 PM
Heights Office
Billings Oral Surgery
& Dental Implant Center
711 West Wicks Lane
Billings, MT 59105
Main:
(406) 655-0170
Hours:
Mon–Thu: 8:00 AM–3:45 PM
Fri:
8:00 AM–1:45 PM
Cody
Billings Oral Surgery
& Dental Implant Center
2910 Big Horn Ave, Suite C
Cody, WY 82414
Main:
(307) 587-5451
Hours:
Mon–Thu: 8:00 AM–3:45 PM
Fri:
8:00 AM–1:45 PM
Sheridan
Billings Oral Surgery
& Dental Implant Center
1274 North Main, Suite A
Sheridan, WY 82801
Main:
(307) 673-4452
Hours:
Mon–Thu: 8:00 AM–3:45 PM
Fri:
8:00 AM–1:45 PM
Social
Main Office
Heights Office
Cody
Sheridan
Google Maps
Main Office
Heights Office
Cody
Sheridan
Helpful Links
Wisdom Teeth Extraction
Meet Dr. Boyce
Meet Dr. Tracy
Notice of Privacy Practices
Surprise Act
Accessibility
Privacy Policy
© 2023. All rights reserved. | Billings Oral Surgery • MT Specialty Dental Services, PLLC/WY , Specialty Dental Services, LLC - Kevin Chad Lambourne, DDS. | Hosted by Specialty Dental Brands™.
close
align-justify
angle-down