6-1592 Regent Avenue West, Winnipeg, Manitoba, R2C 3B4
Date of Referral (required)
Name of Patient (required)
Date of Birth (required)
Patient Phone # (required)
Parent/Guardian (required)
Referring Dentist (required)
Dentist Phone # (required)
Do you have an Pediatric Dentist preference? 1st AvailableDr. J. BiberDr. F. KassDr. C. LekicDr. J. ManiateDr. R. PesunDr. C. YueDr. N. LekicDr. C. ChanDr. S JbaraDr. T. KennedyDr. C. CymbalistyDr. B. Klus
TraumaPain/SwellingGeneral AnestheticEmergency Comments:
Do you have an Orthodontist preference? Dr. M. LekicDr. R. DrummondF. Pinheiro
Please Evaluate for: Comprehensive Orthodontic TreatmentEarly Treatment/Growth Modification Other:
Subscriber Name
Subscriber Date of Birth
Insurance Company
Group/Policy #
ID #
Please call the parent/guardian to arrange appointment YesNo We are sending the most current radiographs YesNo
Please Attach Radiographs:
Upon completion of treatment please have patient return to our office for recall appointments YesNo