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905-607-1112
Referral Form
Book an Appointment
905-607-1112
Referral Form
We are now accepting the
Canadian Dental Care Plan
—
Learn More
Print form
Referral Form
Referral Date
Patient Information
Title
Mr.
Mrs.
Ms.
Miss
Dr.
First Name
Last Name
Date of Birth
Gender
Male
Female
X
Contact Person (if not patient)
Phone
Email
Upload X-Rays
Choose File
Referring Office
Doctor
Phone
Email
Office Name
Location (If more than one)
Reason for Referral
Consultation
Please provide details (urgency, area, etc.)
Extractions including impacted wisdom teeth
Periodontal procedures (Surgical curettage, Pocket Reduction, Bone regeneration)
Gum Grafting
Dental Implants
Pathology removal and Biopsy
Endodontic Treatment
Crown
Restorations
Pulpectomy
Others (Please specify)
Please check teeth/areas to be evaluated
Checkbox Field
55
54
53
52
51
Checkbox Field
19
18
17
16
15
14
13
12
11
Checkbox Field
49
48
47
46
45
44
43
42
41
Checkbox Field
85
84
83
82
81
Checkbox Field
65
64
63
62
61
Checkbox Field
29
28
27
26
25
24
23
22
21
Checkbox Field
39
38
37
36
35
34
33
32
31
Checkbox Field
75
74
73
72
71
Submit
