Patient Information

Referral Date *

Patient Name *

First

Last

Contact Name (If different from patient)

First

Last

Patient/Contact Phone *

Patient Birth Date *

Patient Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Referring Clinician Information

Clinician Name *

Clinician Phone *

Clinician Email *

Clinician Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please send a copy of this report to

• Referring clinician
• Other

Other *

Future Treatment

• Please send this patient back for regular recalls
• Please accept this patient for all future treatment

Teeth Involved

Adult Upper

• 19
• 18
• 17
• 16
• 15
• 14
• 13
• 12
• 11
• 21
• 22
• 23
• 24
• 25
• 26
• 27
• 28
• 29

Adult Lower

• 49
• 48
• 47
• 46
• 45
• 44
• 43
• 42
• 41
• 31
• 32
• 33
• 34
• 35
• 36
• 37
• 38
• 39

Child Upper

• 55
• 54
• 53
• 52
• 51
• 61
• 62
• 63
• 64
• 65

Child Lower

• 85
• 84
• 83
• 82
• 81
• 71
• 72
• 73
• 74
• 75

Radiographs/Pictures

Radiographs/Pictures

• Take as needed
• Sent with patient
• Attached
• Emailed
• Mailed

File Upload

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Date taken

Additional comments on radiographs/pictures

Specialties

Specialist

• Dr. Ryan Margel DMD, MS, FRCD(C) (Endodontic)
• Dr. Mauricio Berco DDS, DMSc, FRCD(C) (Orthodontic)
• Dr. Ihab Kodsi HONBSC, DDS, FRCD(C) (Oral & Maxillofacial)
• Dr. Laura Vertullo, DMD, MSc., FRCD(C) (Pedodontist – Smile City DentAsleep)
• Smile City DentAsleep
• Cone Beam CT

Dr. Ryan Margel *

• Sleep dentistry required
• Consult for possible endodontic treatment
• Consult and endodontic therapy (Same day)
• Consult of a previously endodontically treated tooth
• Prophylactic endodontic therapy (crown/bridge planned)
• Post space requried
• CBCT required
• Other

Other *

Dr. Mauricio Berco *

• Consult for possible orthodontic treatment
• Adult and child comprehensive orthodontic treatment
• Early interceptive treatment for children
• Adult Multidisciplinary treatment
• Other

Other *

Dr. Ihab Kodsi *

• Extractions
• Complex medical history
• Implants
• Other

Extractions *

Complex medical history *

Other *

Smile City DentAsleep *

• Nitrous Oxide
• Sleep dentistry
• General anaesthetic
• Other

Other: *

Cone Beam CT *

• Sextant
• One arch (Maxillary)
• One arch (Mandibular)
• Two archs
• Other

Other *

Remarks/Reason for referral/Diagnosis

Remarks/Reason for referral/Diagnosis

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