For Doctors

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Patient Information

Prefix

First Name *

Last Name *

Birth Date (DD/MM/YYYY)*

Address

Street Address 1*

Street Address 2

Country*

State/Province*

City*

Postal/Zip code*

Phone (Cell)*

Phone (Home)

Patient's Email*

Administrative Information

Referring Dentist*

Ref. Office Name*

Ref. Office Phone*

Ref. Office Email Address*

Date (DD/MM/YYYY)*

Preferred Method of Comunication* CDA SecureSendMailFax

Treatment Information

Patient has had recent radiographs:* YesNo

Date of radiographs: (DD/MM/YYYY)*

Upload files [mfile upload-file-268]

Next

Periodontics

Doctor: First AvaliableEugenie MacKayKaren FungAlison McGuireJanelle HamiltonJacob FitzgeraldXavier Demers

Reason for referral: Specific ConsultationComprehensive ConsultationSoft-Tissue GraftingExtraction(s)Implant(s)BiopsyOther

Please provide diagnosis/rationale for extraction:*

Please write the teeth or area to be treated:*

Endodontics

Doctor: First AvaliableLyon HamburgMichael RappLushen Naidoo

Reason for referral: ConsultationRoot Canal TherapyPeriapical Surgery

Additional diagnostic information: Sensitive to Cold/HotRetreatmentPost Space RequiredSevere Pain/SwellingElective EndodonticsIV Sedation RequieredPain to biting and/or pressure sensitivityNon-specific pain for diagnosisAntibiotics Premedication Required

Please write the teeth or area to be treated:*

Oral Surgery

Doctor: Brent JohnsonWilliam Wayne

Reason for referral: 3rd Molar ExtractionExtraction(s)Implant(s)BiopsyOther

Please provide diagnosis/rationale for extraction:*

Please write the teeth or area to be treated:*

Sleep Apnea and TMD

Doctor: Sherif Elsaraj

Reason for referral: TMD AssesmentSleep Apnea AssessmentOther

Please write the teeth or area to be treated:*

CSI Catherine Street Imaging

Imaging services CBCT ScanLaboratory Services2D Services

Take PAN (Additional Cost)PAN/PA to be sent

Upload files [mfile upload-file-panpa]

Purpose [checkbox* checkbox_cbctpurpose use_label_element "Pathology (Please Specify in Notes)" "Pre-Surgical Implant "Third Molar Relationship" "TMJ Scan" "Airway Analysis" "Orthognathic" "Pathology"]

Report Type:* Screening Report and DICOMSFull Report and Image Portfolio Includes images, nerve tracings and measurementsRush Case (48hrs)

Area to be Scanned:*

Reason for Scan:*

Laboratory Services Clinical PhotosDigital ImpressionsSurgical Guide (Specify Implant Preference Below)Rush Case (48hrs)

Specify Implant Preference*

Specify Planned Implant Location*

2D Services Detail PAN InterpretationLateral Cephalometric ScanPA Cephalometric ScanLateral Cephalometric Scan with MeasurementsRush Case (48hrs)

Notes

Additional Notes

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