Dentist Information
Required Fields **
Dental Office:
Hill Top Dental
2685 2 Ave W, Prince Albert
SK S6V 5E3
Phone: (306) 764-1882
Appointment Type:
Please select:
*
Periodontist
Patient Type:
*
New Patient
Existing Patient
Please select:
Dental Emergency
Immediate Referral Needed
Dental Implants/Self-Referral
General Consultation
Patient Information
Introducing:
*
Patient Email:
example@example.com
D.O.B:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of birth
Phone (Res):
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone (Bus):
Please enter a valid phone number.
Format: (000) 000-0000.
Phone (Cell):
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Information
Primary Insurance
Insurance Carrier:
Policy Holder:
D.O.B:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of birth
Group/Plan No:
Cert No/ID No:
Insurance Carrier:
Policy Holder:
D.O.B:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of birth
Group/Plan No:
Cert No/ID No:
Do you have Secondary Insurance?
Please Select
Yes
No
Treatment Required
Please check all that apply
Periodontal Assessment:
Periodontal disease; comprehensive exam & treatment
Limited periodontal assessment - specific area
Ridge augmentation - prior to fixed bridge or implant placement
Pocket elimination using guided tissue regeneration
Site:
Explain:
Recession:
Localized
Generalized
Assessment:
Scaling and Root Planning
Guided Tissue Regeneration
Gum Contouring
Socket Preservation
Sinus Lift
Orthodontics:
Frenectomy
Fiberotomy
Crown exposure (Palatal)
Crown exposure (Labial)
Pre-orthodontic treatment clearance
Post-orthodontic treatment assessment
Implants:
Surgical Placement
Surgical Replacement
Other Notes:
Referral Information
Referral:
Please Select:
*
Dentist Referral
Self Referral
Referred By Dr:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
Referral Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Attach File(s): Please include the date the radiographs were taken
*
Browse Files. Please include the date the radiographs were taken.
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Date the radiographs were taken:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
OR
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