Online Doctor Referral Form - Ontario Oral Surgery Group

Doctor Referral Form

Preferred Clinic : BrockvilleNorth BayToronto

Please select a Brockville doctor : Dr. Stephen HoDr. Ahmed Almuzayyen

Please select a North Bay doctor : Dr. Nick KatsikerisDr. Stephen HoDr. Johnson CheungDr. Ahmed Almuzayyen

Please select a Downtown Toronto doctor : Dr. Stephen HoDr. Karl Cuddy

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:

D	5554535251	6162636465	G
	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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