2023 Referral Form

WE GROW HEALTHY SMILES
#17, 3919 Richmond Road S.W Calgary, AB T3E 4P2 info@glamorgandental.ca p. 403.242.4303 f. 403.686.4070
Referring Doctor or Clinic Information:
Clinic Name*
Physician or Dentist Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone*
Fax
Patient Information:
Patient Name:*

First NameLast Name
Address*

Street Address

CityState / Province

Postal / Zip Code
Cell*
Email*
example@example.com
Best contact method
Date of Birth*

MonthDayYear
Date
Reason for Referral:*

Screening for Sleep Disordered BreathingConsultation for oral appliancfe therapy with mandibular advancement device or expansion therapyBotulinum Toxin Injection for TMJ DisordersAcquisition Large CBCTOther
Has the patient tried CPAP?*

YesNo
Diagnosis?*

MildModerateSevereOther
Diagnostic sleep study available?*

YesNo
Please include diagnostic sleep study and interpretation with referral.
File Upload

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Please select the following if you agree:

I approve the use of an oral appliance to treat obstructive sleep apnea.I approve recurring level 3 sleep studies for verification of appliance efficacy.
Comments:
Signature*

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WE GROW HEALTHY SMILES