test required field CF7

    Please select a doctor*
    Dr. Nach DanielDr. Eric St-GermainDr. Karim Al-KhatibAny doctor

    Patient Name*

    Today's date*

    Date of Birth*

    Patient Email

    Is this for a child?
    NoYes

    Parent/Guardian

    Telephone Number*

    Address

    Please select one

    Dental InsuranceIndian AffairsSocial AssistanceNot applicable

    Type of treatment :

    ExtractionExposureTMJApical SurgeryPathologyImplantologyJaw SurgeryPreprosthetic Surgery

    Adult Teeth Charting

    D

    1817161514131211

    2122232425262728

    G

     

    4847464544434241

    3132333435363738

     

    Youth Teeth Charting:

    D

    5554535251

    6162636465

    G

     

    8584838281

    7172737475

     

    X-Ray Request*

    X-Ray 1:
    Date*

    X-Ray 2:
    Date*

    X-Ray 3:
    Date*

    Max. 15MB / file, allowable formats JPG or PNG, Dates: day month year

    Referring dentist* :

    Office email* :

    Remarks

    If you need a copy of this form for your records, click the print button below BEFORE sending the form

    Print this page

    Basic GPG test below