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(705) 746-5859
Book an Appointment
Refer a Patient
About
Services
Dental Emergencies
Implant Surgery & Extractions
Sedation & Sleep Dentistry for Adults
Sedation & Sleep Dentistry for Your Child
Cosmetic Dentistry
Root Canal Therapy
Cleanings and Prevention
FAQ
Contact
Menu
About
Services
Dental Emergencies
Implant Surgery & Extractions
Sedation & Sleep Dentistry for Adults
Sedation & Sleep Dentistry for Your Child
Cosmetic Dentistry
Root Canal Therapy
Cleanings and Prevention
FAQ
Contact
About
Services
Dental Emergencies
Implant Surgery & Extractions
Sedation & Sleep Dentistry for Adults
Sedation & Sleep Dentistry for Your Child
Cosmetic Dentistry
Root Canal Therapy
Cleanings and Prevention
FAQ
Contact
Menu
About
Services
Dental Emergencies
Implant Surgery & Extractions
Sedation & Sleep Dentistry for Adults
Sedation & Sleep Dentistry for Your Child
Cosmetic Dentistry
Root Canal Therapy
Cleanings and Prevention
FAQ
Contact
Book an Appointment
About
Services
FAQ
Contact
Book an Appointment
Refer a patient
Date
REFERRING DOCTOR/CLINIC:
First Name
Last Name
DOB:
Telephone Home:
Cell:
SERVICES REQUIRED:
Consultation
Extractions
Implants: Indicate system of preference
Nobel Biocare
Neodent
Hiossen
Paediatric Sedation Dentistry
Root canal Therapy:
Initial treatment
Retreatment
In the event that prognosis of tooth is hopeless/poor ie. Crack, do we have permission to extract the tooth
Yes
No
AREA OF CONCERN (Please indicate tooth numbers/region):
SEDATION SERVICES:
Consult
Nitrous
Oral sedation/IV Sedation
Deep Sedation/ GA
Comments/ detailed reason for referral:
Relevant Medical History : (Please attach your Medical History form to this referral)
In the event that we decide the patient would be best served by seeing a specialist, do we have your permission to refer the patient out?
Yes
No
Submit
Email:
admin@bowesdentalcentre.ca
Fax:
(705) 746-8653
Phone:
(705) 746-5859
