Doctor Referral Form

*If referring a patient for sedation or general anesthesia, please ensure the patient has a recent health physical completed (within 12 months) by their family physician or pediatrician and ask the family bring a copy with them to their consultation or have it faxed to 506-855-1919.

Youth Teeth Charting

Adult Teeth Charting

You can upload JPEG, PNG, or PDF files. Max. size is 5MB.

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

Temporary location

192 Church St. 
Moncton, NB E1C 4Z9

TEL: (506) 855-1212
FAX: (506) 855-1919

EMAIL: [email protected]

Office Hours

Mon: 8am – 4pm
Tues: 8am – 4pm
Wed: 8am – 4pm
Thur: 8am – 4pm
Fri: 8am – 12 noon