61 Long Ct. Suite 101, Thousand Oaks, CA 91360
Phone (805) 301-9870 Fax (805) 496-1141
www.thousandoaksimplants.com

Referred for extraction of teeth indicated:

1

2

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32

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Right

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Left

X-rays

General anesthetic instructions prior to surgery:
(If you are to sleep): Do not eat or drink anything for at least 6 (six) hours before surgery. Make arrangements for someone to drive you home following surgery.

Jonathan K. Nakano, D.M.D

61 Long Ct. Suite 101, Thousand Oaks, CA 91360 Phone (805) 301-9870

To complete your health history forms prior to your appointment, please go to www.thousandoaksimplants.com and click on patient forms.

Please follow the prompts, complete forms, print and bring to your appointment.