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905-607-1112
Referral Form
Home
About Us
Our Team
Dr. Sahil Gagnani
Dr. Irina Kuslya
Invisalign® Clear Aligner
Canadian Dental Care Plan
Services
Cosmetic Dentistry
General Dentistry
Dental Implant
Emergency Dentistry
Wisdom Tooth Extractions
Veneers
Zoom® Teeth Whitening
Other Services
Dental Bridges
Dental Checkups
Dental Crowns
Dentures & Partial Dentures
Fluortide Treatment
Full Mouth Reconstruction
Oral Cancer Screening
Regular Oral Hygiene Treatment
Endodontic
Wisdom Tooth Extractions
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Referral Date
Patient Information
Title
Mr.
Mrs.
Ms.
Miss
Dr.
First Name
Last Name
Date of Birth
Gender
Male
Female
X
Contact Person (if not patient)
Phone
Email
Upload X-Rays
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Referring Office
Doctor
Phone
Email
Office Name
Location (If more than one)
Reason for Referral
Consultation
Please provide details (urgency, area, etc.)
Extractions including impacted wisdom teeth
Periodontal procedures (Surgical curettage, Pocket Reduction, Bone regeneration)
Gum Grafting
Dental Implants
Pathology removal and Biopsy
Endodontic Treatment
Crown
Restorations
Pulpectomy
Others (Please specify)
Please check teeth/areas to be evaluated
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85
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65
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29
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