SCOMS - Oral Medicine Referral Form

URGENT Oral Medicine referrals must include a clear, high-quality colour photograph to be accepted.

Photographs are strongly encouraged for all other pathology referrals and help support timely, appropriate triage.
I. Demographic Information

Patient Information
Patient Name

First NameLast Name
Patient Cell phone number
Insert 10 digit Phone NumberFormat: (000) 000-0000.
Patient Land Line phone number
Insert 10 digit Phone NumberFormat: (000) 000-0000.
Additional/alternate phone number
Insert 10 digit Phone NumberFormat: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provincial Health Care Insurance Plan Number
Provincial Personal Health Care Number
Date of Birth

MonthDayYear
Email
example@example.com
II. Referring Information
Referring Doctor Name
Referred by
Referring Doctor's Email
example@example.com
Referring Doctor's Phone Number
Insert 10 digit Phone NumberFormat: (000) 000-0000.
Referring Doctor's Postal Code

Street Address

Street Address Line 2

CityState / Province

Postal code
III. Reason for Referral
Mucosal Lesion:
Leukoplakia   Lichen Planus   Ulceration   Fibroma/Mucocele   Mass

Infection:
Candidiasis   Herpes   Other Infection

Other:
Xerostomia   Sjorgren's Syndrome workup   Radiation complication   Chemotherapy complication
III. Description/Sites/Pertinent Information
Description/Sites/Pertinent Information:
IV. Related Medical History/Comments
Related Medical History/Comments
Quality Colour Clinical Photographs

Browse Files

Cancelof
Date Photos Taken

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

URGENT Oral Medicine referrals must include a clear, high-quality colour photograph to be accepted.

I. Demographic Information

II. Referring Information

III. Reason for Referral

III. Description/Sites/Pertinent Information

IV. Related Medical History/Comments