Referral Form

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Patient's Name

Parent or Guardian (optional)

Address (optional)

Daytime Phone Number the patient may by reached at (optional)

Business or Cell phone number (optional)

Email

Patient's Date of Birth

Reasons for Referral (optional)

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 (optional)

How does the patient pays for the dental services?

ODSP

Healthy Smiles Ontario

First Nation

Private Insurance

Name of Referring Dentist

Office Phone Number

Office Fax Number (optional)

Email Address

Please make sure the size of each file is lower than 2 MB. Files will be attached to the email and sent with your referral form

Please upload radiograph

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