ANCASTER: DOC+ Referral Form

Referral Form, DOC+ Ancaster
Referring Doctor Information
Doctor First & Last Name

Doctor First NameDoctor Last Name
Doctor Email
example@example.com
Referral Submission Date

MonthDayYear
Date
Patient Information
Date

MonthDayYear
Date
Patient First & Last Name*

Patient First NamePatient Last Name
Patient Birthdate

MonthDayYear
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.Format: (000) 000-0000.
Patient Work Phone Number
Please enter a valid patient work or cellphone number.Format: (000) 000-0000.
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

CityState / Province

Postal / Zip Code
Periodontal Services

Please Check All That Apply
Select your Doctor

Dr. Daniel James Fortino, PeriodontistFirst Available
Periodontal Services

Comprehensive &/or Specific Periodontal ConsultSoft Tissue GraftingDental Implant PlacementBone GraftingPerform a Final Digital Scan of Implant & Send us Final Crown for Insert (For Dental Implant Placement)Crown LengtheningOther
Dental Sites or Areas of focus
Oral Surgery Services

Please Check All That Apply
Select your Doctor

Dr. Daniel James Fortino, PeriodontistFirst Available
Oral Surgery Services

Impacted Wisdom TeethOral Pathology/Oral MedicineExtractionsHard/Soft Tissue PathologyTooth Exposure & BondConsideration for Arch Implant RehabilitationOther
Dental Sites or Areas of Focus
Endodontics Services

Please Check All That Apply
Select your Doctor

Dr. Hengameh Bakhtiar, Endodontist
Sites
Radiology

Radiology
Area & Reason for Radiology
Anesthetic Options To Be Discussed

Please Check All That Apply
Anesthetic Options

NitrousIntravenousOral SedationSedationGeneral Anesthesia
Other Services

Please Check All That Apply
Other Services of Interest

Sleep Dentistry (Treatment under General Anesthesia) Pediatric & AdultTMD/Myofunctional Treatment
Radiographs

Please Check All That Apply
Delivery

Have Been MailedEmailed To Info@Doc-Plus.caSent With PatientTaken In Your Office & Copy Sent For Our RecordsUploaded to this Referral
Type

Bitewing X-RayFull Mouth SurveyPano
UPLOAD PATIENT X-RAY & OTHER RELEVANT DOCUMENTS HERE

Cancelof
Patient Insurance Information

Please Fill Out The Information Below
Patient Insurance Status*

Patient Has NO Dental InsurancePrivate InsuranceCDCPODSPHSONIHB
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

Please Leave Any Comments Below
Should be Empty:

Referral Form, DOC+ Ancaster

Referring Doctor Information

Patient Information

Periodontal Services

Oral Surgery Services

Endodontics Services

Anesthetic Options To Be Discussed

Other Services

Radiographs

Patient Insurance Information

Secondary Insurance

Additional Comments