Referral

First Name *

Last Name

Date of birth *

Guardian

Phone Number *

Email Address *

Reason for referralSpeech Pathology (expansion, airways, frenectomy, crowding, spaces, tongue habitOrthodontic Exam (narrow palate, crowding, cosmetics)TMD - Joint disfunction (jaw or muscle pain, misalignment, grinding)Halitosis (bad breath)General Restorative & Dental HygieneDental Emergency (teeth, tissues, trauma, cold sores)Oral Surgery (wisdom teeth extractions, implants, velscope/cancer screening)Periodontics (gum disease, recessions, cold sore, frenectomy)Endodontics (tooth infection, abscess, trauma)Snoring and/or Sleep Apnea/Appliance Therapy (please include diagnosis and intake forms if possible)Sedation requiredOther

Additional Information0 / 180

Please call *Before consult/examinationAfter consult/examination

Referring Doctor *

Date

We appreciate your referral and will contact the patient to book an appointment

Please forward any additional information to info@crystallinedental.com or fax to +1 905 303-2333.

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Mon: 9am-4pm
Tue: 8am-7pm
Wed: Closed
Thu: 9am-5pm
Fri: 9am-4pm
Sat: 9am-5pm
Sun: Closed

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