Download Dr. Jay M. Bukzin Dr. Patrick R. Friend

Dr. Jay M. Bukzin
Dr. Patrick R. Friend
7915 Lake Manassas Drive, Suite 304, Gainesville, VA 20155
703 753 7933 [email protected]
1050 North Highland Street, Suite 220, Arlington, VA 22201
703 483 9591 [email protected]
Oral, Facial Cosmetic & Implant Surgery
www.meyerclinic.com
Patient’s name
Date
Referred by
Procedure / consultation requested
Additional comments
Implant type preferred
Additional procedures
Head & Neck Pathology
Craniofacial Deformities
Orthognathic Surgery
Infections of the Head & Neck
Facial / Oral Trauma
Pre-orthodontic Surgery
Facial / Oral Reconstruction
Anesthesia Services
Facial Cosmetic Surgery
Rejuvenation
Temporomandibular Joint
Disorders / Myofacial Pain
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L
T
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PERMANENT/IMPLANT PLACEMENT
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Dr. Jay M. Bukzin
Dr. Patrick R. Friend
7915 Lake Manassas Drive, Suite 304, Gainesville, VA 20155
703 753 7933 [email protected]
1050 North Highland Street, Suite 220, Arlington, VA 22201
703 483 9591 [email protected]
Oral, Facial Cosmetic & Implant Surgery
www.meyerclinic.com
Important pre-operative information
Please provide the following information at the time of
your consultation:
•
•
•
•
Surgical referral
Complete list of medications you are taking
Medical and dental insurance forms or cards
Relevant radiographs (X-rays, CT scans, MRIs)
Your initial appointment will typically consist of a consultation explaining your diagnosis and treatment
options. Occasionally, surgery can be performed the
same day. However, your treatment plan may require
input from your primary care physician, specialist, or
preoperative testing, resulting in a second appointment
for your surgery.
If you require or request IV sedation or general anesthesia for surgery, a pre-operative consultation is
required. Please refrain from eating or drinking for at least
8 hours prior to surgery, unless instructed otherwise.
Please wear comfortable clothing and make arrangements with a friend or family member for transportation
to your home.
Please alert us well in advance of your surgery if you
have a medical condition or are taking any medication
that may affect the surgery.
These are general instructions for your anesthesia and
surgery. We will provide you with detailed information
during your consultation and surgery appointments.
A parent of guardian must accompany all patients
under the age of 18.
We do accept most PPO Insurance plans. A portion
of your responsibility will be asked to be paid on the
day of the consultation, and prior to the scheduling of
service.
1050 North Highland St., Suite 220
Arlington, VA 22201
1 1 t h S t.
Washington Blvd.
Washingto
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Ballston
Metro
Free Parking
10th St N
Free Parking
1st level
10th St. N.
10th St. N.
N Pollard St
10th St. N.
2nd level
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Arlington
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Central Library
d Street
on Street
N. Irving Street
10th Rd. N.
North Highlan
North Huds
Washington Blvd
10th St. N.
Stonewall
Golf Club
Blvd
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Parking
M
Virginia
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Metro