Referral Form, Collingwood
Referring Doctor Information
Doctor First & Last Name
Doctor First Name
Doctor Last Name
Doctor Email
example@example.com
Referral Submission Date
-
Month
-
Day
Year
Date
Patient Information
Date
-
Month
-
Day
Year
Date
Patient First & Last Name
*
Patient First Name
Patient Last Name
Patient Birthdate
-
Month
-
Day
Year
Date
If patient is a minor, name parent(s)
*
Enter "N/A" if not applicable
Patient Phone Number (Home/Cell)
*
Please enter a valid patient phone number.
Patient Work Phone Number
Please enter a valid patient work or cellphone number.
Patient Email
*
If the information is not applicable (N/A), kindly include a note in the "additional comments" section at the bottom of this form if there is no email on record.
Patient Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Periodontal Services
Please Check All That Apply
Select your Doctor
Dr. Daniel James Fortino, Periodontist
First Available
Dr. Jon Perlus, Periodontist
Periodontal Services
Comprehensive &/or Specific Periodontal Consult
Soft Tissue Grafting
Dental Implant Placement
Bone Grafting
Perform a Final Digital Scan of Implant & Send us Final Crown for Insert (For Dental Implant Placement)
Crown Lengthening
Other
Dental Sites or Areas of focus
Oral Surgery Services
Please Check All That Apply
Select your Doctor
Dr. Daniel James Fortino, Periodontist
First Available
Dr. Jon Perlus, Periodontist
Oral Surgery Services
Impacted Wisdom Teeth
Oral Pathology/Oral Medicine
Extractions
Hard/Soft Tissue Pathology
Tooth Exposure & Bond
Consideration for Arch Implant Rehabilitation
Other
Dental Sites or Areas of Focus
Radiology Services
Please Check All That Apply
Radiology
Radiology
Area & Reason for Radiology
Anesthetic Options To Be Discussed
Please Check All That Apply
Anesthetic Options
Nitrous
Intravenous
Oral Sedation
Sedation
General Anesthesia
Other Services
Please Check All That Apply
Other Services of Interest
Pediatric Dentistry
Endodontic
Sleep Dentistry
TMD/Myofunctional Treatment
Radiographs
Please Check All That Apply
Delivery
Have Been Mailed
Emailed To Info@Doc-Plus.ca
Sent With Patient
Taken In Your Office & Copy Sent For Our Records
Uploaded to this Referral
Type
Bitewing X-Ray
Full Mouth Survey
Pano
UPLOAD PATIENT X-RAY & OTHER RELEVANT DOCUMENTS HERE
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient Insurance Information
Please Fill Out The Information Below
Patient Insurance Status
*
Private Insurance
CDCP
ODSP
HSO
NIHB
Patient Has NO Dental Insurance
Patient Insurance Company
*
If the patient is not covered by dental insurance, please indicate "N/A."
Group#, ID/Certificate, Policy#
*
If the patient is not covered by dental insurance, please indicate "N/A."
Secondary Insurance
If relevant, kindly provide your secondary insurance information below.
Secondary Patient Insurance Company
If the patient is not covered by dental insurance, please indicate "N/A."
Secondary Insurance Group#, ID/Certificate, Policy#
If the patient is not covered by dental insurance, please indicate "N/A."
Additional Comments
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