Referral Form

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.

Patient Information
Name:*
First Last
Date of Birth:*

(mm/dd/yyyy)
Date Submitted:*

(mm/dd/yyyy)
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:*
Email:*

If you do not have the patient's email please use the generate button to create a token email.
Referral Information
Requested Surgeon:
- Dr. Ed Zeligman
- Dr. H. Richard Biewald
- Dr. Hassan G. Moghadam
- Dr. Kevin J. Butterfield
- Dr. Taylor P. McGuire
- Dr. Adam M. Irvine
- Dr. Andrew Wing Cheong Lee
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
Teeth or Area to be Treated
- 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
- TMJ
- Sleep Apnea
- Others (please describe below)
Comments:
Name
This field is for validation purposes and should be left unchanged.