Online Referral Form

To submit referrals, x-rays and photos securely through our website, please use the form below.

We would like to introduce our New Patient Management System, where your referral and x-ray is read by one of our specialty trained treatment coordinators before scheduling the initial appointment.

This system ensures your patient is being seen in the most timely manner possible.

In some cases we may be able to offer your patient treatment on the day of their consultation therefore reducing the amount of appointments and starting treatment sooner.

Please note;

Periodontal consultations please provide us with a recent OPG (no older than 12-18 months) - if there is not one available, we have the facility to take one onsite.
Extraction appointments please provide us with a PA, or OPG as we may be able to offer a extraction on the day of consultation
Implant consultations we will take a dental CBCT scan on site at the time of consultation, there is no need to refer your patient to another facility.
Miscellaneous consultations: please provide relevant x-rays and images

Patient's Personal Information

Title

First Name *

Last Name *

Phone *

Alternative Phone

Date of Birth *

Address *

EmailBy providing this: Your patient will receive confirmation of their appointment time and our location

Referral Information

Referring Doctors Full Name *

Practice Name:

Referring Dentist Email *

Patient Scheduling Method *

Please call my patient to schedule appointment Patient will call to schedule appointment

Please choose form the following doctors: *

Dr. Adam RosenbergDr. Jessica WeiDr. Alex KhominskyPeriodontal Hygienist Open Referral - Please schedule in order to ensure my patient's individual needs are met as quickly as possible

Reason For Referral

Periodontal Referrals require a OPG, please provide more information.

I will upload recent OPGPlease take a OPG onsite and share back with meI have referred my patient to have a OPGNo OPG available

Please note a recent OPG is one that has been taken within the last 12- 18 months. If you have referred your patient for a OPG please ensure to send to us once received.

Remarks *Please provide as much information as possible including site/s number

Please Note: by providing recent radigraphs you are assisting in the Treatment Coordinating process.

Periodontal consultations: please provide us with a recent OPG
Extraction appointments: please provide us with a PA and or OPG we may be able to offer a extraction on the day of consultation
Implant consultations: we will take a dental CBCT scan on site at the time of consultation, there is no need to refer your patient to another facility.
Miscellaneous consultations: please provide us with relevant x-rays and images

Upload Files:

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Upload recent images, intraoral and full mouth radiographs. Hold "Shift Key" on Windows or "Command Key" on Mac to select multiple files.

Upload Written Referral

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You may prefer to upload a written referral

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