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Offering Advanced Endodontic Care in Burlington, Ontario

Referral Form

Please fill out the referral form below for your patient:

Referral

From*
First Last
To*
First Last
We are referring*
First Last
Birthdate
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Reason For Referral
- Consultation Re
- Treatment (as requested)
Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.
Relevant History
(Indicate any special factors – either dental or medical – such as known allergies and specific medical problems relevant to diagnosis and treatment.)
Best Time for Appointment
- Please call the patient
- Patient will call
- An appointment has been made.
- Radiographs are enclosed.
- Please return radiographs after use.
- Notify on completion.
- Please report – written
- Please report – by phone
- Other records are available.
Radiographs Upload
Max. file size: 2 GB.
Comments/Questions
Preference
This field is for validation purposes and should be left unchanged.

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Serving the Following Cities
Hamilton Ontario • Oakville Ontario • Grimsby Ontario • St. Catherines Ontario • Brantford Ontario
Mississauga Ontario

Referring Doctors

Learn more about Referral Form Learn more about Endodontic Case Assessment Learn more about Treatment Planning Options

3155 Harvester Road, Suite 405
Burlington, Ontario L7N 3V2

Tel: Advanced Endodontics Phone Number (905) 632-3456 Fax: (905) 632-6061

[email protected]

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