Refer a patient - Georgian Mall Family Dental

Referring Doctor Information

Name of referring doctor *

Date of Referral *

Referring doctor phone number *

Time *

Referring Doctor Email *

How did your hear about us? *

Referral submitted by

Patient Information

Patient first name *

Patient work number *

Patient last name *

Patient email

Patient phone number *

Patient date of birth *

Patient Information

Patient Information *

Included in the submission
Given to Patient
Please take
Mailed

Pediatrics

Pediatrics *

Comprehensive treatment
Specific treatment
Emergency treatment
Sedation

Periodontics

Oral Surgery

Oral Surgery *

Extraction
Pathology
Trauma
Other

Endodontics

Prosthodontics

Sedation

Sedation *

Please discuss with patient

Cone Beam Computed Tomography

TMJ (PLEASE CHECK ALL THAT APPLY)

Cone Beam Computed Tomography *

Close
Bite registration

PATHOLOGIC INVESTIGATIONS

PATHOLOGIC INVESTIGATIONS *

Intra-osseous
Soft tissue
Temporomandibular joints

IMPLANTS

IMPLANTS *

Stent provided
Measurements
Pathology check only

ENDODONTICS

ENDODONTICS *

Root fracture
Apical pathoses
Perforation
Canal anatomy

Special Instructions

X-Ray upload

Click or drag a file to this area to upload.

Consent *

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ABOUT

Dental Insurance & Financing
Office Tour
Blog

SERVICES

Wisdom Tooth Removal
Dental Implant
Sleep Dentistry
Sport Guards
General Cleaning
Dentures
Porcelain Veneers
Porcelain Crowns
Emergency Dental Care
Orthodontics
Invisalign
CBCT Scanner
Dental Bonding
Full mouth Reconstruction
Teeth Whitening
Oral Cancer Screening
Gum Treatments

HOURS

Monday – Friday 7:30 am – 9 pm
Saturday – 9:30 am – 6 pm
Sunday – 10 am – 5 pm

Georgian Mall Family Dental
509 Bayfield St, Barrie, ON
L4M 4Z8

(705) 503-7773
georgianmallfamilydental@gmail.com

Located on the Upper Level
inside Georgian Mall,
across from Sportchek

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