Lo Elliott Orthodontics
Request for Orthodontic Consultation - Dentist Referral
PRACTICE INFORMATION
*
Practice Name
*
Referring Dentist / Staff
*
Practice Email
PATIENT INFORMATION
Child
Adult
*
Patient Legal First and Last Name
Female
Male
Add gender information (optional)
Our entire team is committed to making sure every patient feels safe, welcome and respected.
*
Patient Birthdate
Patient Mailing Address
Please enter at least one method on contact for patient
Home Phone
Cell Phone
Email Address
First and Last name
Relationship
Home Phone
Cell Phone
First and Last name
Relationship
Home Phone
Cell Phone
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
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:
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Date PAN was taken:
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newpatient@perfectsmile.ca
| 250.562.2113 |
www.perfectsmile.ca