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- Referral Form
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  - 2019 Education Day
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Refer A Patient

Refer A Patient

About
Procedures
For Referring Doctors
- Referral Form
- Educational Events
  - Education Day
  - 2019 Education Day
For Patients
Resources
Locations
Contact

Referral Form

Contact Us

Referral

It is an honour to be included on your healthcare team. Thank you for entrusting your patients to us.

You may refer patients by filling out and submitting this secure online Referral Form or by printing out a blank form and returning it to us.

"*" indicates required fields

Patient Information

First Name*

Last Name*

Date of Birth:*

MM slash DD slash YYYY

(mm/dd/yyyy)

Date Submitted:*

MM slash DD slash YYYY

(mm/dd/yyyy)

Address:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:*

Email:

Referral Information

Requested Surgeon:

First Available

Dr. Ian Buckley

Dr. Hassan G. Moghadam

Dr. Kevin J. Butterfield

Dr. Taylor P. McGuire

Dr. Adam M. Irvine

Dr. Andrew Wing Cheong Lee

Dr. John E. Guenther

Dr. Harshdeep S. Mangat

Select Location:

Referring Dentist:*

Referring Dentist Email:*

Do You Have Radiographs or Documents to Upload?

Yes

No

Given to Patient

File Upload:*

(Upload up to 5 files, images and/or documents, with a maximum file size of 12MB per file.)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 12 MB, Max. files: 5.

Does the Patient have Insurance?*

Yes

No

PRIMARY POLICY INFORMATION

Policy Holder First Name

Policy Holder Last Name

Policy Holder Gender (as registered with dental plan)

Male

Female

Policy Holder Date of Birth

MM slash DD slash YYYY

Policy Holder's Relationship To Patient

Self

Parent

Spouse

Commonlaw

Insurance Company Name

Group/Plan/Contract

Member/Certificate/ID

Is the patient a student 21 years or older.?

Yes

No

School Name

SECONDARY POLICY INFORMATION

Policy Holder First Name

Policy Holder Last Name

Policy Holder Gender (as registered with dental plan)

Male

Female

Policy Holder Date of Birth

MM slash DD slash YYYY

Policy Holder's Relationship To Patient

Self

Parent

Spouse

Commonlaw

Insurance Company Name

Group/Plan/Contract

Member/Certificate/ID

Is the patient a student 21 years or older?

Yes

No

School Name

Teeth or Area to be Treated

teeth

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

55

54

53

52

51

61

62

63

64

65

85

84

83

82

81

71

72

73

74

75

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Treatment Information

Select one or more treatments:*

Implants

Extractions

Impacted Teeth

Lesion

Orthognathic Surgery

Infection

Others (please describe below)

Please add additional details for the "Lesion" or "Other" selection.

Location*

Measurement*

Shape*

Color*

Duration (how long have they had it)*

Symptomatic*

Additional Comments:

Comments

This field is for validation purposes and should be left unchanged.

About Us

Argyle Associates Oral & Maxillofacial Surgeons is one of the largest, most established groups of its kind in Canada. Since 1976, we have provided the complete scope of oral and maxillofacial procedures.

Our Locations

BARRHAVEN:10-3091 Strandherd Drive
Barrhaven, ON K2G 4R9

ORLEANS & SURGICENTRE EAST: 750 Taylor Creek Drive
Orleans, ON K4A 0Z9

Our Locations

CARLING & SURGICENTRE WEST: 100‐2255 Carling Avenue
Ottawa, ON K2B 7Z5

KANATA: 15‐499 Terry Fox Drive
Kanata, ON K2T 1H7

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