Patient Referral Form
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Date of Birth
Phone #
Type
Home
Work
Mobile
Other
Ext
Phone #
Type
Home
Work
Mobile
Other
Ext
Email
Reason for Referral
Patient is being referred to:
Orthodontic consultation with Dr. Jennifer Tan
Periodontal consultation with Dr. Martin Lin
*Both* Orthodontic consultation with Dr. Jennifer Tan and Periodontal consultation with Dr. Martin Lin
Specific Details
Early Interceptive Orthodontic Treatment
Comprehensive Orthodontic Treatment
Combined Orthodontic and Periodontal Treatment
Comprehensive Periodontal Treatment
Dental Implants
Specific Periodontal Consultation
Details (tooth number, sites, medical concerns, etc.):
Is there anything else we should know in order to assist your patient more effectively?
Radiographs
Please forward us any recent radiographs taken at your office (within the last 24 months) and the date on which they have been taken.
1.
Orthodontic consultation:
Please send us the most recent panoramic radiograph available, even if it is a few years old.
2.
Periodontal consultation:
A panoramic radiograph, periapical radiographs, and/or vertical bitewings are all helpful for our assessment and diagnosis. Please send
all
recent radiographs, even if the patient is being referred for a specific site.
If current radiographs are unavailable, we will take the necessary radiographs at the consultation appointment.
Please select one of the following:
Radiographs will be forwarded
None available
Referring Dentist Information
Referring Doctor Name
Practice Name
Practice Phone Number
Please forward radiographs to info@orthoperio.ca
