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Patient Medical History
Referring Offices
Patient Medical History
Referring Offices
Patient Referral Form
Location / Doctor
Preferred Location
*
Windsor
Leamington
Referral Date
*
Referred-To Oral Surgeon
*
First available
Dr. Sadek
Dr. Paulo
Dr. Paterson
Patient Information
First Name
*
Last Name
*
Date of Birth
*
Parent / Guardian Name
Phone Number
*
Email Address
*
Schedule Appointment
*
Please call patient to book
Patient will call
Scheduled - please attach referral/additional information below
Dental Insurance
*
Private
CDCP
None
Referring Office
Referred By
*
Phone Number
*
Email Address
*
Reasons for Referral
please provide as much details as possible
Imaging
Cone Beam CT
Panorex
Intraoral Scan
Remarks
*
RIGHT
18
48
17
47
16
46
15
45
14
44
13
43
12
42
11
41
21
31
22
32
23
33
24
34
25
35
26
36
27
37
28
38
LEFT
RIGHT
55
85
54
84
53
83
52
82
51
81
61
71
62
72
63
73
64
74
65
75
LEFT
Please Verify Teeth for Extraction (Tooth Number(s))
*
Radiographs
Radiographs / Clinical Photos
*
Given to Patient
Please Take
Attached with This Referral
X-ray Date
X-RAYS
UPLOAD X-RAYS THAT WILL BE ATTACHED TO THIS REFERRAL FORM.
x-rays
Max file size: 5 MB
Combined max size: 20 MB
Allowed types: pdf, doc, docx, png, jpg
Max number of files allowed: 10
Complete and Send