We Put the Confidence Back in Your Smile

Search

Home
About Us
Services
Patient Referral
Contact

Home
About Us
Services
Patient Referral
Contact

Search

Patient Referral

There are two ways to fill out our patient referral form.

Referral Form - fillable PDF - fill it in, print it off and fax to (519) 336-2941. (Form can also be printed off and filled in by hand, then faxed to the office.)

Or fill in the online form below.

We will contact you shortly to confirm receipt of the referral. Thank you.

Step 1 of 3

33%

Referring Doctor(Required)

Patients Name(Required)

Patient Date of Birth(Required)

MM slash DD slash YYYY

Patient Address

Street Address Address Line 2 City Province Postal Code

Patient Home Phone(Required)

Please enter the best phone number to contact this patient.

Patient Cell Phone

Insurance(Required)

If none, please enter the word none.

Denture Required - Upper(Required)

Complete

Partial

Immediate

Implant Removable

Implant Fixed

None - Lower Only

Please select all that apply.

Denture Required - Lower(Required)

Complete

Partial

Immediate

Implant Removable

Implant Fixed

None - Upper Only

Please select all that apply.

Is there any future dental work planned/needed?(Required)

Yes

No

Hygiene Apt - Date completed/expected to be completed

MM slash DD slash YYYY

Extractions - Tooth #

Extraction - Date completed/expected to be completed

MM slash DD slash YYYY

Root Canal- Tooth #

Root Canal - Date completed/expected to be completed

MM slash DD slash YYYY

Fillings - Tooth #

Fillings - Date completed/expected to be completed

MM slash DD slash YYYY

Other

Other - Date completed/expected to be completed

MM slash DD slash YYYY

Additional Notes:

Comments

This field is for validation purposes and should be left unchanged.