Referrals

Dear Doctor and Dental Team,

Please Download our referral form (pdf) or complete the form below.

"*" indicates required fields

Patient Info

Patient Name*

First Last

Patient Age*

Parent Name*

First Last

Phone Number*

Referrer

Referring Doctor*

First Last

Phone Number*

Referring Practice*

Email*

Reason for Referral*

CARIES

TRAUMA

SEDATION

GENERAL ANESTHESIA

OTHER

Comments

Radiographs*

Mailed

Emailed

None Taken

With Patient

Type

2 Bitewings

Panoramic

Periapicals

Details

If periapicals, provide details

Phone

This field is for validation purposes and should be left unchanged.

Contact Us

Address
585 Ontario Street South, Suite 208
Milton, ON L9T 2N2

Phone
905-878-3030

Milton Pediatric Dentistry
585 Ontario Street South, Suite 208
Milton, ON L9T 2N2

T: 905-878-3030 F: 905-636-1414