17300 Yorba Linda Blvd Suite J, Yorba Linda, CA 92886
Phone (714) 515-6364
www.yorbalindaoms.com

Referred for extraction of teeth indicated:

1

2

3

4

5

6

7

8

9

10

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12

13

14

15

16

32

31

30

29

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17

Right

A

B

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D

E

F

G

H

I

J

T

S

R

Q

P

O

N

M

L

K

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.

Dr. Daniel Yang, DDS, MD

17300 Yorba Linda Blvd Suite J, Yorba Linda, CA 92886 Phone (714) 515-6364

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

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