15124 Yonge St. Aurora, Ontario

Referrals

Referring Provider Name:
Referring Clinic Name:
Referring Clinic Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referring Clinic Phone Number
Referring Clinic Email
To:
- Dr. German Ramirez
- Dr. Nasim Shafie-Zadeh
Introducing:
Patient*
First Last
Parent / Guardian:*
First Last
Birthdate
MM slash DD slash YYYY
Age
Telephone:
Email
REASON FOR REFERRAL
Major Concern
- Interceptive Orthodontic Program
- Frenectomy Consultation
- Restorative/Recare
- Other
Other (Please Explain the concern)
TREATMENT (as requested):
(Please provide specialist with appropiate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.)
RELEVANT HISTORY:
(Indicate any special factors - either dental or medical - such as know allergies ands specific medical problems relevant to diagnosis and treatment.)
- Please take radiographs on arrival
- Radiographs will be emailed
File
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