Lo Elliott Orthodontics
Request for Orthodontic Consultation - Dentist Referral
PRACTICE INFORMATION
PATIENT INFORMATION
Child
Adult
Male
Female
Add gender information (optional)
Our entire team is committed to making sure every patient feels safe, welcome and respected.
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
If unknown, please provide best estimation of last appointment
Yes
No
Uncertain
Planned Treatment/Date of Appointment &/or Additional Details
Poor
Fair
Good
Excellent
Unknown
DOCUMENT UPLOAD
Please upload the following documents for the patients:
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newpatient@perfectsmile.ca
| 250.562.2113 |
www.perfectsmile.ca