Smile On Clinics Patient Referrals

Patient Details and Treatment Information
Patients First Name*
Patients Last Name*
Patients Email*
Patients Phone Number*
Date of Birth*

DayMonthYear
Has the client confirmed that they are experiencing acute or chronic pain?*

YesNo
Has the client confirmed experiencing acute or chronic mental illness/stress related to their dental condition?*

YesNo
Medical Condition*

EdentulousSevere Incisal/ occlusal wearPeriodontal diseaseMalocclusionOvercrowdingCracked / broken teethGingivitisIll-fitting denturesImpacted teethCompromised oral healthTerminal TeethMissing teethOral DisabilitySevere / Widespread Decay / CariesMisaligned Jaw / over, under or cross biteBone lossAbscess / infectionMobile / loose teethOther
Medical Treatment*

ExtractionsBone graftingBridgesVeneersFillings BridgesFull Mouth RehabilitationPartial DenturesFull DenturesRoot Canal treatmentDental ImplantsDental Restoration – CrownsBraces / InvisalignGingivectomyFull ClearanceAdhesive restorationOther
Treatment Duration*

1 - 2 weeks1 Month3 – 4 months5 - 6 months6 - 9 months18 - 24 months – orthodontic onlyOther
Comments
Patients Treatment Plan*

Cancelof
Clinic Details
Clinic Name*
Treating Dentist*
Dentist Name*
Contact Name*
Phone Number*
Clinic Email*
example@example.com
Application Payment
Payment Method*
Should be Empty:

Clinic Details