REFERRING DOCTOR
           
 Last Name:*  First Name*    
 Telephone:*  Fax:  Email:
           
 PATIENT INFORMATION
           
 Last Name:*  First Name*  D.O.B.
 Street Address:
 City:  Province:  Postal Code:
 Home Phone:  Cell/Work:  Email:*
 Patient's preferred method(s) of communication      MAIL    PHONE    EMAIL
 Health Card:*      
 Parent / Guardian  Last Name:  First Name:
           
 DENTAL INSURANCE INFORMATION
 
None   Group/Private   Community Services  
 if you selected Group / Private Insurance above, please fill out this section:
 Group Name:
 Plan Holder: (Last)     (First)  
 Relationship with Plan Holder: SELF      Spouse      Common Law      Dependant
 Plan Holder's D.O.B:  Employer of Plan Holder:
 Plan / Group Number:  ID / Certificate Number:
       
 CITADEL SURGEONS  (Please indicate preference of surgeon(s) for your patient)
 
First Available     Marco A. Chiarot     Joel E. Powell     Other
 
 REASON FOR REFERRAL
 
 
 MEDICAL HISTORY OR MEDICATIONS OF NOTE
 
 
 APPOINTMENT
 
  ASAP     Elective     Has been booked    
 Appointment Date:  Time:
  
 XRAYS
 
  Included     Being Mailed     Emailed     Please Take     N/A    
 Other Enclosures:  Date of Exposure:
 
 AREA/TOOTH NUMBER(S) FOR TREATMENT (adult)
 
     
     
 
 AREA/TOOTH NUMBER(S) FOR TREATMENT (child)