Associates for Oral & Maxillofacial Surgery

Your Name
First Last Initial
Phone number
Procedure you need to schedule for
Doctor preference (if any) (Dr. Savage or Dr. Rajagopal)
Referred by
Would you like additional general anesthesia or nitrous? (local anesthesia is always included)
Do you have a current X-Ray? (Within the last year)
- Yes
- No
Do you take blood-thinning or bone density medications?
- Yes
- No
If so, what kind?
Date / time preferences
How did you hear about us?
Where would you like your appointment? (Medford or Grants Pass)
Initials
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