Referral Information Date*: Name*: Mailing Address: Postal Code: Tel#: Email*:* Fax #: Please leave this field empty. Patient Information Name* Date of Birth*: Mailing Address*: Contact Number; Email Postal Code Please check off preferred contact:PhoneEmail Please complete the following information Urgency of care: *Emergency CareUrgentRoutine Dental X-Rays:*NO X-rays - Please take x-raysSent with PatientMailedCeph RadiographCBCT Digital X-Rays: Printed NOT accepted. Upload Limit: 1MB Reason for Referral: Full Mouth Implant RehabilitationPartial Mouth Implant RehabilitationSingle Implant Placement & RestorationOther Other Relevant Dental / Medical History: Current Medications: Please: Call the office at 416-586-4745 ext 6765 for email information to send digital radiographs. Appointment Date and Time* Cancellation Policy:This appointment time is reserved for your patient. If unable to attend, our office must be notified at least 3 working days in advance to avoid cancellation charges.
