Referral Forms & Prescriptions

We extend our sincere appreciation for your support to our practice throughout the years. We recognize our referral community is invaluable to our growth. We will continue to provide the care you expect,  far exceeding the typical standard of care, in order to meet the needs of you and your patients. We are continuously adding the latest in equipment and technology, affording us the most aseptic, state-of-the art surgical facility in the area.

Please, call our office to make arrangements to tour our facility, we want to know you.  We look forward to extending our expertise, helping to make your patients' journey a comfortable and pleasant experience.  Our office philosophy is Patient's First!  To us, your referrals are not only patients, they are family.

Referring doctors,  please use the following links to help us expedite the care of your patient.

Office Referral Form

CT Scan Prescription

Laboratory Guide Prescription

Drilling Prescription

South Florida Oral & Facial Cosmetic Surgery, Dental Implant Center is an authorized Keystone Dental, EasyGuide imaging center and laboratory in the fabrication of radiographic guides necessary during the CT scanning process. 

Keystone Dental will utilize the submitted Drilling Prescription, EasyGuide surgical file and radiographic guide with X-marker to fabricate the Surgical Guide.

Fabrication of Radiographic Guide with X-Block

To fabricate a radiographic guide our facility requires from the referring dentist:

           * EasyGuide - Laboratory Guide Prescription

           * EasyGuide – X-Marker

  OPTION A:

• Radiographic Guide: Tooth replacement between adjacent teeth (one or more) in single arch

• Patient arch impressions, bite registration, model fabrication

• Fabrication of acrylic radiographic guide (Barium sulfate in desired position(s) of tooth replacement)

• Mounting EasyGuide X-marker

• Dentist will receive:

                   Patient’s models

                   Patient’s radiographic guide with X-marker

Fee: $250.00

  OPTION B:

• Radiographic Guide: Tooth replacement for partially or edentulous arch

•  Patient arch impressions, bite registration, model fabrication

• Duplicate partial or complete denture into acrylic

• Fabrication of acrylic radiographic guide (Barium sulfate in desired position(s) of tooth replacement)

• Mounting EasyGuide X-marker

• Dentist will receive:

                   Patient’s models

                   Patient’s radiographic guide with X-marker

Fee: $275.00

CT Scan of Patient: Radiographic Guide with X-marker (Per Arch)

• CT Scan of patient with radiographic guide/X-marker

• CT Scan will be reviewed by Board Certified Oral and Maxillofacial Radiologist

• Patient’s DICOM Data will be loaded into EasyGuide Software with X-marker registration

• Dentist will receive:

               Patient’s report from Radiologist

               CD of patient’s CT Scan file with traditional viewing software

              CD of patient’s EasyGuide File with registered X- marker readyfor planning

 Fee: $250.00

• Each requested additional CT scan of the same arch will cost $200.00

• If radiologist interpretation is indicated then additional fees may apply

**Please Note:

Our online forms use the Adobe Acrobat 5 Plugin. Please download the free plugin from Adobe's web site if it is not already installed on your system. It is important that you have version 5 of the plugin, in order to successfully use our form.