North Bay Oral Surgery

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

Doctor Referral Form

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

Today's date (yyyy-mm-dd)
Patient Name
Is this for a child?
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 :
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X-Ray 1: Date*

X-Ray 2: Date*

X-Ray 3: Date*

Max. 15MB / file, allowable formats JPG or PNG, Dates: yyyy-mm-dd

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