Please enable JavaScript in your browser to complete this form.Patient InformationReferral Date *Patient Name *FirstLastContact Name (If different from patient)FirstLastPatient/Contact Phone *Patient Birth Date *Patient Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeReferring Clinician InformationClinician Name *Clinician Phone *Clinician Email *Clinician Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePlease send a copy of this report toReferring clinicianOtherOther *Future TreatmentPlease send this patient back for regular recallsPlease accept this patient for all future treatmentTeeth InvolvedAdult Upper191817161514131211212223242526272829Adult Lower494847464544434241313233343536373839Child Upper55545352516162636465Child Lower85848382817172737475Radiographs/PicturesRadiographs/PicturesTake as neededSent with patientAttachedEmailedMailedFile Upload * Click or drag a file to this area to upload. Date takenAdditional comments on radiographs/picturesSpecialties SpecialistDr. Hesam Abbas-Tehrani DDS, MSc Perio (Periodontal)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. Jonathan Mahn DDS (Implants & Extractions)Smile City DentAsleepCone Beam CTDr. Roland Leung *Sleep dentistry requiredGeneralized periodontal evaluation and treatmentSpecial concernsGuided tissue regenerationSurgical crown lengtheningImplant consultationSoft tissue graftAesthetic gingival recontouringRidge augmentationOtherOther *Dr. Ryan Margel *Sleep dentistry requiredConsult for possible endodontic treatmentConsult and endodontic therapy (Same day)Consult of a previously endodontically treated toothProphylactic endodontic therapy (crown/bridge planned)Post space requriedCBCT requiredOtherOther *Dr. Mauricio Berco *Consult for possible orthodontic treatmentAdult and child comprehensive orthodontic treatmentEarly interceptive treatment for childrenAdult Multidisciplinary treatmentOtherOther *Dr. Ihab Kodsi *ExtractionsComplex medical historyImplantsOtherExtractions *Complex medical history *Other *Dr. Jonathan Mahn *ImplantsExtractionsOtherOther *Smile City DentAsleep *Nitrous OxideSleep dentistryGeneral anaestheticOtherOther: *Cone Beam CT *SextantOne arch (Maxillary)One arch (Mandibular)Two archsOtherOther *Remarks/Reason for referral/DiagnosisRemarks/Reason for referral/DiagnosisPrint this pageSubmit15588