Dentist Referral Form

Dentist
Referral Form

Doctor’s Referral Form

  • Patient Information:
  • MM slash DD slash YYYY
  • REASON FOR REFERRAL:

    Mark the teeth or areas to be treated:

    Permanent

  • Primary

  • Hidden
    (Please provide specialist with appropriate details of problem; i.e. areas of concern, using F.D.I. tooth numbering system.)
    (Indicate any special factors – either dental or medical - such as known allergies and specific medical problems relevant to diagnosis and treatment.)
  • Referred by:

Testimonials

What Smile Denture & Implant Customers Are Saying

Excellent service. Got an appointment on short notice for urgent service. Rapid and efficient. Very helpful in explaining repair to be done on dentures. I definitely recommend this clinic.
Joanne Laflamme
Joanne Laflamme
My husband's denture broke and we were from out of province. Caner saw him within an hour and had his repair done same day. The staff (especially Caner) was friendly, professional and knowledgeable. The repair was excellent! I would recommend this clinic to anyone.
Noah Martinez
Noah Martinez
I was having terrible trouble with my bottom denture. Caner explained how he was going to fix it, he did within the week and now, holy moly, I can eat again. Fantastic!
Mick Pates
Mick Pates
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