Brockville  Oral Surgery

135 Ormond St Suite 101
Brockville, ON K6V 5Y2

North Bay Oral Surgery

180 Shirreff Ave. Suite 240
North Bay, ON P1B 7K9

Doctor Referral Form

Preferred Clinic :   BrockvilleNorth Bay
Please select a North Bay doctor :   Dr. Robert Van WinckleDr. Nach DanielDr. Karim Al-Khatib
Please select a Brockville doctor :   Dr. Stephen Ho

Today's date (yyyy-mm-dd)
Patient Name
Is this for a child?
Date of Birth (yyyy-mm-dd) Telephone Number
Please select one (if this is applicable to your patient)
Dental InsuranceIndian AffairsSocial AssistanceNot Applicable
Type of treatment :
ExtractionExposureTMJApical SurgeryPathologyImplantologyJaw SurgeryPreprosthetic Surgery
Adult Teeth Charting

D 1817161514131211 2122232425262728 G
  4847464544434241 3132333435363738  
Youth Teeth Charting:

D 5554535251 6162636465 G
  8584838281 7172737475  
X-Rays request :
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