135 Ormond St Suite 101 Brockville, ON K6V 5Y2
180 Shirreff Ave. Suite 240 North Bay, ON P1B 7K9
Preferred Clinic : BrockvilleNorth Bay
Please select a North Bay doctor : Dr. Nick KatsikerisDr. Stephen HoDr. Johnson CheungDr. Ahmed Almuzayyen
Please select a Brockville doctor : Dr. Stephen HoDr. Ahmed Almuzayyen
Today's date (yyyy-mm-dd)
Patient Name
Is this for a child? NoYes
Parent/Guardian
Date of Birth (yyyy-mm-dd)
Telephone Number
Address
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:
5554535251
6162636465
8584838281
7172737475
X-Rays request : X-Ray AttachedX-Ray EmailedPlease Take X-Ray
X-Ray 1: Date*
X-Ray 2: Date*
X-Ray 3: Date*
Max. 15MB / file, allowable formats JPG or PNG, Dates: yyyy-mm-dd
Referring dentist*:
Your email*:
Remarks
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