Referring a Patient

For Doctors

Coquitlam Office


Patient's Name
Patient's Phone
Insurance Info
Referred By
Office Phone
Office Email
Appointment Date

Location

Coquitlam

Tooth/Area of Concern

8 7 6 5 4 3 2 1
YOUR LEFT/PATIENT'S RIGHT
8 7 6 5 4 3 2 1
1 2 3 4 5 6 7 8
YOUR RIGHT/PATIENT'S LEFT
1 2 3 4 5 6 7 8

Reason for Referral

Consult Consult and Treat Call to Discuss

Tooth Status

RCT started, please complete.
Tooth has a post Tooth has temporary Crown
Tooth has a fixed prothesis
Permanent Cement Temporary Cement

After RCT

Restore access with permanent filling,
amalgam resin
Restore access with temporary filling.
Leave post space Place post

Attachments

Attach File:

Remarks



Note: We will confirm by email that we've received your referral. In case you don't hear back from us, please follow up with a phone call as your message might not have gone through. We want to make sure we take care of your patient accordingly. Thanks!

Thank you! Your email has been sent, we will respond shortly.



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East Vancouver
Fax: (604)873-0719

Coquitlam
Fax: (604)464-0419



If you would like additional information, please don't hesitate to contact us at
Coquitlam
(604)464-0411
Vancouver
(604)873-0717