Name First Last Date of birth MM slash DD slash YYYY Guardian PhoneEmail 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 call Before consult/examination After consult/examination Referring Doctor Date 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.
