Referral Form
Vitality Oral Health | 110 - 2210 2 Street SW Calgary, AB T2S 3C3 | P: 403-441-8739 F: 403-541-0871 | hello@vitalityoralhealth.com
I am referring for:
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Please Select
Dental Treatment
Biopsy
Patient’s Legal Name:
DOB
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Month
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Day
Year
Date
Patient’s Preferred Name:
Contact Name (if different from patient):
Relation:
Contact Info:(C):
Contact Info:(H):
Contact Info:(E):
AHC#:
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Check any indicating reason(s) for this referral:
AISH/Alberta Works Coverage
Heart Problems
Anxiety Requiring Sedation
Behaviour Requiring Sedation
Mentally Challenged / Dementia
Physically Challenged
Wheelchair User Requiring Lift
Lung or Breathing Problems
Organ Transplant
Diabetes
Arthritis or Other Joint Issue
Seizure Disorder
Neurologic or Other (MS, ALS, etc.)
Infectious Issues (HIV, HepB, HepC, etc.)
Addiction Problems
Dialysis or Other Renal Failure
Mental Health Challenges
Snoring / Sleep Apnea
Other medical concerns, medications (e.g. blood thinners), allergies, etc.:
Known dental concerns:
One-Time Specific Visit:
Yes
No
Ongoing Care:
Yes
No
Emailed:
Yes
No
Referring Doctor:
Facility:
PRAC ID (if applicable):
(P):
(F):
(E):
Additional Information:
We accept all government and private insurance plans.
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