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Online Referral Form
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Home
About Us
Locations
Our Dental Services
For Patients
Online Referral Form
Contact Us

Home
About Us
Locations
Our Dental Services
For Patients
Online Referral Form
Contact Us

Referral Form

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Patient's Name

Parent or Guardian

Address

Daytime Phone Number the patient may by reached at

Business or Cell phone number

Email

Patient's Date of Birth

Reasons for Referral

Mentally and /or physically challenged patient

Needle phobic

Need sedation for extensive dental treatment

Have a high gag reflex

Have had traumatic experiences

Difficulty getting numb

Uncooperative pediatric patient

Select the service needed

Please provide a brief treatment plan

How does the patient pays for the dental services?

ODSP

Healthy Smiles Ontario

First Nation

Private Insurance

Referring Dentist Information

Name of Referring Dentist

Office Phone Number

Email Address

Radiographs Upload

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FullName2

One Dental Scarborough

3-3430 Finch Ave. East Scarborough, ON M1W 2R5

416-499-3322

office hours

Mon - Thu: 08:00AM – 08:00PM
Fri: 08:00AM – 06:00PM
Sat - Sun: 08:00AM - 05:00PM

Facebook-f Instagram

One Dental Scarborough

3-3430 Finch Ave. East Scarborough, ON M1W 2R5

416-499-3322

office hours

Mon - Thu: 08:00AM – 08:00PM
Fri: 08:00AM – 06:00PM
Sat - Sun: 08:00AM - 05:00PM

Facebook-f Instagram

One Dental North York

557 Marlee Ave,
North York, ON M6B 3J6

416-256-7506

office hours

Mon - Fri : 08:00AM – 10:00PM
Sat: 9:00AM – 05:00PM
Sun: Closed

summer breeze dental

4190 Finch Ave E Unit 128, Scarborough, ON M1S 4T7

416-490-8446

office hours

Mon - Tue: 10:00AM – 08:00PM
Wed: 10:00AM – 06:00PM
Thu : 10:00AM – 07:00PM
Fri: 10:00AM – 06:00PM
Sat: 9:00AM – 05:00PM
Sun: Closed

Facebook-f Twitter Google Instagram

One Dental Burlington

2465 Walkers Line
Burlington, ON L7M 4K4

289-337-5757

office hours

Mon: 09:00AM – 08:00PM
Tue: 09:00AM – 07:00PM
Wed: 09:00AM – 05:00PM
Thu : 09:00AM – 05:00PM
Fri: 09:00AM – 04:00PM
Sat - Sun: Closed

Dentist @ Milton

9037 Derry Rd UNIT 16 Milton, ON L9T 7Y9

289-878-5225

office hours

Mon: 09:00AM – 08:00PM
Tue: 09:00AM – 07:00PM
Wed: 09:00AM – 05:00PM
Thu : 09:00AM – 05:00PM
Fri: 09:00AM – 04:00PM
Sat: 09:00AM – 04:00PM
Sun: 09:00AM – 04:00PM

One Dental Scarborough

3-3430 Finch Ave. East Scarborough, ON M1W 2R5

416-499-3322

office hours

Mon - Thu: 08:00AM – 08:00PM
Fri: 08:00AM – 06:00PM
Sat - Sun: 08:00AM - 05:00PM

Facebook-f Instagram

One Dental North York

557 Marlee Ave,
North York, ON M6B 3J6

416-256-7506

office hours

Mon - Fri : 08:00AM – 10:00PM
Sat: 9:00AM – 05:00PM
Sun: Closed

summer breeze dental

4190 Finch Ave E Unit 128, Scarborough, ON M1S 4T7

416-490-8446

office hours

Mon - Tue: 10:00AM – 08:00PM
Wed: 10:00AM – 06:00PM
Thu : 10:00AM – 07:00PM
Fri: 10:00AM – 06:00PM
Sat: 9:00AM – 05:00PM
Sun: Closed

Facebook-f Twitter Google Instagram

One Dental Burlington

2465 Walkers Line
Burlington, ON L7M 4K4

289-337-5757

office hours

Mon: 09:00AM – 08:00PM
Tue: 09:00AM – 07:00PM
Wed: 09:00AM – 05:00PM
Thu : 09:00AM – 05:00PM
Fri: 09:00AM – 04:00PM
Sat - Sun: Closed

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