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Referring Doctor's Name*
Referring Clinic Name*
Referring Clinic Phone Number*
Referring Clinic Email*
Parent's Name*
Parents Contact Email*
Parents Contact Number*
Date of Referral*
Patient #1 Name*
Patient #1 Last Name*
Patient #1 Date of Birth*
Reason for Referral (Check All That Apply)General AnestheticRoutine CareWork needs to be done under sedationWork needs to be done under a general anestheticSpecific procedure onlyReferral needs URGENT attentionPatient needs pediatric home due to behaviour related challengesEMERGENCY (patient will be seen same or next working day)Other
Please Specify
Have radiographs been taken?YesNo
Radiographs Attached? (see below to attach)YesNo
Date Radiographs Taken
Please provide any pertinent information regarding the patient’s dental or medical history.
trueAdd Another Patient
Patient #2 Name
Date of Referral
Patient #2 Date of Birth*
Reason for ReferralGeneral AnestheticRoutine CareOther
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