Patient Referral Form - Paris Dental Centre

At this time, we are not accepting referrals for pediatric (12 and under) general anesthetic or IV sedation for restorative work, we are in the process of streamlining this service and hope to to be accepting referrals again soon.

We continue to offer N2O for all pediatric restorative work.

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 *

Click or drag a file to this area to upload.

Date taken

Additional comments on radiographs/pictures

Specialties

Specialist

Dr. 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 DentAsleep
Cone Beam CT

Dr. Roland Leung *

Sleep dentistry required
Generalized periodontal evaluation and treatment
Special concerns
Guided tissue regeneration
Surgical crown lengthening
Implant consultation
Soft tissue graft
Aesthetic gingival recontouring
Ridge augmentation
Other

Other *

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 *

Dr. Jonathan Mahn *

Implants
Extractions
Other

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

Print this page

71728