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4181 Holiday St NW
Canton, OH 44718

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789 White Pond Drive
Suite B, Akron, OH 44320

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For dentists and physicians, Dr. David C. Ash and Dr. R. Neil Sundheimer have provided an online referral form. For the convenience of both medical professionals and patients, please complete and submit the form below. Patient data will be kept private and secure through our system. Help our oral and maxillofacial surgeons in Akron, and Canton, Ohio, get your patients the care they need.

Downloadable Referral Form

Patient Referal Form

Patient Information

Extractions

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Other Procedures
Alveoloplasty
Biopsy
Incision and Drainage
Lesion Evaluation
Exposure
Infection
Expose and Bond
Soft Tissue
Frenectomy
Consultation
TMJ
Implants
Orthognathic Evaluation
Pre-Prosthetic
Cleft Lip and Palate
Cosmetic
Other
Implants
Surgical Template

Referring Doctor Information
X-Ray Being Mailed
X-Ray Given to Patient
Please Take An X-Ray

X-Rays Attached Below:

Comments
All Fields Marked with '*' must be completed to submit the form

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