Referrals

Online Form

If you wish to refer a patient to our offices, please fill out the online form below for pedo and Ortho patients with all x-rays. and correspondence

Patient Name *

Patient Last Name

Patient Birth Date

GenderMaleFemalePrefer not to answer

Parent/Guardian Full Name *

Patient Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Phone Number

Medical History0 / 180

Consultation is requested for (check all that apply) *CariesInfectionTraumaPathologyManagementOther

Insurance *PrivateNoneHealthy Smiles OntarioOther

Insurance Carrier

Insurance ID Number

Insurance Policy Number

Records *BitewingsPeriapicalsPanoramicPhotosNo Records

Have you performed any treatment for this patient?

If “Yes”, please explain

Date of Radiographs

Additional Patient Information

When treatment is complete, how would you like us to manage this patient?Refer back to your officeKeep patient here until olderParent to decide

Office Phone

First Name *

Last Name

Office Location *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address *

Select Doctor (not required)

Select Location *

Upload a file

Drag and Drop (or) Choose Files

Please upload your Xray or other documents here

We are a friendly team of dentists, hygienists and receptionists who work together to ensure that you receive the best treatment you require.