Lo Elliott Orthodontics
Request for Orthodontic Consultation - Dentist Referral
PRACTICE INFORMATION
*
Practice Name
*
Referring Dentist / Staff
*
Practice Email
PATIENT INFORMATION
*
Is patient a child or an adult?
Child
Adult
*
Patient Legal First and Last Name
*
Legal Sex
Male
Female
Add Gender information
Add gender information (optional)
Our entire team is committed to making sure every patient feels safe, welcome and respected.
*
Patient Birthdate
Patient Mailing Address
*
Patient Contact Information
Please enter at least one method on contact for patient
Home Phone
Cell Phone
Email Address
*
Parent/Guardian Information
First and Last name
Relationship
Home Phone
Cell Phone
Additional Parent/Guardian Information
First and Last name
Relationship
Home Phone
Cell Phone
Insurance Information (Check all that apply)
MCFD - 077030 - PHN (10 digits)
FNHA - 40000 - Status Number
Cleft Palate/Syndrome - PHN (10 digits)
Dental Insurance
*
Specific Areas of Concern
*
Date of most recent examination/cleaning
If unknown, please provide best estimation of last appointment
*
Is there pending dental work?
Yes
No
Uncertain
Planned Treatment/Date of Appointment &/or Additional Details
*
Oral Hygiene Grade:
Poor
Fair
Good
Excellent
Unknown
Additional Notes (if needed)
DOCUMENT UPLOAD
Please upload the following documents for the patients:
Routing/Patient Information Slip
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Dated Panographic X-ray
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Date PAN was taken:
Perio-Charting
for Adults
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newpatient@perfectsmile.ca
| 250.562.2113 |
www.perfectsmile.ca