Oral Medicine Referral Form

I. Demographic Information

Patient Information
Patient Name *

First Name Last Name
Patient cel-phone

Area Code Phone Number
Additional/alternate phone number

Area Code Phone Number
Alberta Health Care Insurance Plan
AHC Personal Health Number
Date of Birth *

Month Day Year
Email
example@example.com
II. Referring Information
Referring Doctor
Referred by
Referring Doctor's Email
example@example.com
Referring Doctor's phone

Area Code Phone Number
Referring Doctor's postal code *

Street Address

Street Address Line 2

Postal code
Reason for Referral

II. Referring Information
Mucosal Lesion:
Leukoplakia   Lichen Planus   Ulceration   Fibroma/Mucocele   Mass

Infection:
Candidiasis   Herpes   Other Infection

Other:
Xerostomia   Sjorgren's Syndrome workup   Radiation complication   Chemotherapy complication
Description/Sites/Pertinent Information

II. Referring Information
Description/Sites/Pertinent Information:
III. Related Medical History/Comments
Related Medical History/Comments
Please provide a photo, related labwork and x-rays:

Browse Files

Cancel of
X-rays Date taken

Month Day Year
Date
Should be Empty: