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*
Format: (000) 000-0000.
Patient Email*

Confirmation Emailexample@example.com
Referred By *

PrefixFirst NameLast Name
Office Phone Number*
Format: (000) 000-0000.
Referral Type
YesNo
YesNo
Tooth(s) to be extracted
Remarks or Special instructions
Reason for Referral
Teeth to be treated
Comments
Restore access opening as neededPrepare post spacePlace temporary restorationPlace post/buildup as needed
Treatment
YesNoImmediateDelayed
YesNo
YesNo
YesNo
YesNo
Tooth Number
YesNo
Other Reason
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