Name First Last Date of birth Date Format: MM slash DD slash YYYY GuardianPhoneEmail Tooth Number(s)Reason for referral Speech Pathology (expansion, airways, frenectomy, crowding, spaces, tongue habit Orthodontic Exam (narrow palate, crowding, cosmetics) TMD - Joint disfunction (jaw or muscle pain, misalignment, grinding) Halitosis (bad breath) General Restorative & Dental Hygiene Dental Emergency (teeth, tissues, trauma, cold sores) Oral Surgery (wisdom teeth extractions, implants, velscope/cancer screening) Periodontics (gum disease, recessions, cold sore, frenectomy) Endodontics (tooth infection, abscess, trauma) Snoring and/or Sleep Apnea/Appliance Therapy (please include diagnosis and intake forms if possible) Sedation required Other Additional InformationPlease callBefore consult/examinationAfter consult/examinationReferring DoctorDate Date Format: MM slash DD slash YYYY We appreciate your referral and will contact the patient to book an appointment Please forward any additional information to records@midtowndental.ca or fax to 416.966.3362.
