Referral Form

Referring Dentist
Referring Office:*
Referring Dentist:*
Date:
MM slash DD slash YYYY
Email:*
Phone:*
Extension
Patient Information
Patient Name:*
First Last
Gender:*
- Male
- Female
Date of Birth:*
MM slash DD slash YYYY
Patient’s Home Number:
Patient’s Work Number:
Extension
Patient’s Cell Number:
Reason for Referral:
- General evaluation
- Specific area
- Implant placement
Specific Area:
Crown lengthening:
Frenectomy:
Mucogingival defect(s):
Localized periodontal defect(s):
Implant tx:
Preferred case completion:
- Healing collars
- Final abutments in place
Notes:
Diagnostic films:
- Are needed
- Patient will bring
- Have been mailed
- Attached
File Attachment:
Drop files here or

Max. file size: 128 MB.
Anticipated Restorative Tx:
- Crown(s)
- Bridge(s)
- Removable prosthesis
- Implant supported
Details:

About Lancaster Dental

At Lancaster Dental, we are committed to providing comprehensive dental care for the entire family. We have been proudly serving our Kitchener community’s dental needs since 1978.

Kitchener Dentist Office

Lancaster Dental
493 Lancaster Street West
Suite #206
Kitchener, ON N2K 1L8
519-578-9670
[email protected]

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Referral Form

Referring Dentist

Patient Information