Referral Form

General Information

Date of Referral (required)

Name of Patient (required)

Date of Birth (required)

Patient Phone # (required)

Parent/Guardian (required)

Referring Dentist (required)

Dentist Phone # (required)

For Pediatric Dentistry

Do you have an Pediatric Dentist preference?
 1st Available Dr. J. Biber Dr. F. Kass Dr. C. Lekic Dr. J. Maniate Dr. R. Pesun Dr. C. Yue Dr. N. Lekic Dr. A. Huminicki Dr. A Salles

This is a referral regarding:

 Trauma Pain/Swelling General Anesthetic Emergency

Comments:

For Orthodontics

Do you have an Orthodontist preference?
 Dr. M. Lekic Dr. R. Drummond

Please Evaluate for:
 Comprehensive Orthodontic Treatment Early Treatment/Growth Modification
Other:

Insurance Information

Subscriber Name

Subscriber Date of Birth

Insurance Company

Group/Policy #

ID #

Additional Details

Please call the parent/guardian to arrange appointment  Yes No
We are sending the most current radiographs  Yes No

Please Attach Radiographs:






Upon completion of treatment please have patient return to our office for recall appointments  Yes No

Preferred Location

 1426 McPhillips Street, Winnipeg, MB 2107 Pembina Hwy, Winnipeg, MB 6-1592 Regent Ave W, Winnipeg, MB


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