Provider Referral

REFERRAL FORM

If you would like to refer a patient to our practice, please provide us with the information below
Introducing*

First NameLast Name
Patient Phone Number*
Patient Email*

Confirmation Emailexample@example.com
Referred By *

PrefixFirst NameLast Name
Office Phone Number*
Referral Type
Does the patient require antibiotics prior to dental treatment?*

YesNo
Please call patient*

YesNo
Tooth(s) to be extracted
Remarks or Special instructions
Reason for Referral
Teeth to be treated
Comments
When treatment is completed, please:

Restore access opening as neededPrepare post spacePlace temporary restorationPlace post/buildup as needed
Treatment
Implants

YesNoImmediateDelayed
Gingival Recession

YesNo
Graft for Root Coverage

YesNo
Ridge Augmentation

YesNo
Crown Lengthening

YesNo
Tooth Number
Other

YesNo
Other Reason
Radiograph / Clinical Photo

Being MailedGiven to PatientPlease TakeNo X-RayAttached with Referral (See below)
X-Rays are attached, what date were they taken:

MonthDayYear
Date
Please note that at this time, we only provide minimal conscious sedation (nitrous sedation) at our facility.

Other Procedure
Case Notes
Patient Files

Cancelof
Area of Interest (Tooth #)
Additional Information
KM Dental Group
703 The Queensway, Etobicoke ON M8Y 1L2
416 255 9901
Queensway@KMDentalGroup.com
Should be Empty:

REFERRAL FORM