Referral Form Contact Us 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 InformationFirst 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:OntarioQuebecPostal Code:Home Phone:Cell Phone:*Email: Referral InformationRequested 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 Select Location:BarrhavenCarling & Surgicentre WestOrleans & Surgicentre EastKanataReferring 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 Select files Accepted file types: jpg, png, pdf, Max. file size: 12 MB, Max. files: 5. Does the Patient have Insurance?* Yes No PRIMARY POLICY INFORMATIONPolicy Holder First NamePolicy Holder Last NamePolicy 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 NameGroup/Plan/ContractMember/Certificate/IDIs the patient a student 21 years or older.? Yes No School NameSECONDARY POLICY INFORMATIONPolicy Holder First NamePolicy Holder Last NamePolicy 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 NameGroup/Plan/ContractMember/Certificate/IDIs the patient a student 21 years or older? Yes No School NameTeeth or Area to be Treatedteeth 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 InformationSelect 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:EmailThis field is for validation purposes and should be left unchanged.