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Mark Lawhon

Referring Doctors

We file all insurances.

Same day surgeries are available.

Consultation Appointments Please Have The Patient Bring:

All insurance information.
List of all medications.
Any patient under the age of 16 must bring their guardian.
Adults may bring ONE family member with them
Consultation are needed for all IV Sedations or General Anesthesia.

Doctor Referral Form

Referring Doctor*
First Last
Patient Name*
First Last
Patient Phone*
Requested Appointment Date:*
MM slash DD slash YYYY
Requested Appointment Time:*

: Hours

Minutes

AM/PM
Patient being referred for:*
- I. Extraction or Surgical Removal of Teeth indicated by the following number(s)
Adult*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
Child*
- A
- B
- C
- D
- E
- F
- G
- H
- I
- J
- K
- L
- M
- N
- O
- P
- Q
- R
- S
- T
II. Other Oral Surgery*
- Biopsy
- Exposure(Tooth#)
- Apicoetomy(Tooth#)
- Frencectomy:
- Implants:
- Preproshetic:
- Other:
- TMJ Pain:
Special Instructions

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611 W Palmetto St, Florence, SC 29501