STANDARD DENTAL REFERRAL FORM
APPROVED BY THE CANADIAN DENTAL ASSOCIATION
FROM: ________________________________________________ _ _ _ _ _ ___
TO: _________________________________________________ _ _ _ _ _ ____
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We are referring:
Patient:
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Birthdate: _____________________________________________________
Parent/Guardian: ________________________________________________
Telephone:
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(M / D / Y)
Address:
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Telephone: _____________________________________________________
REASON FOR REFERRAL:
CONSULTATION RE: ____________________________________________________________________________________________________
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TREATMENT (as requested):
(Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.)
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RELEVANT HISTORY:
(Indicate any special factors either dental or medical such as known allergies and specific medical problems relevant to diagnosis and treatment.)
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Please call the patient.
Patient will call.
An appointment has been made.
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Radiographs are enclosed.
Please report written
Please report by phone
Post-referral maintenance
By specialist
In this office
To be discussed
Please return radiographs after use.
Notify on completion.
Other records are available.
SIGNED: _____________________________________________________________________________DATE: ______________________________________
