Doctor Referral Form Final – East Coast Pediatric Dentistry

East Coast Pediatric Dentistry

Your Moncton Specialist

1-506-855-1212 | [email protected]

Doctor Referral Form

Patient's Name

Parent/Guardian

Child's age

Date of Birth

Telephone Number

Address

Please select one (if this is applicable to your patient)

Dental Insurance Indian Affairs Social Assistance

Type of treatment :

Extraction(s) Restorative Trauma Root Canal Therapy Treatment with Nitrous Oxide Treatment with Sedation Treatment under General Anesthesia Transfer of Care

*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.

Medical history:

Healthy Medically Complex Behaviour Challenges

Please provide more details of the patient's medical history:

Does the Patient require SBE prophylaxis?

Yes No

Has the child failed treatment attempts

Yes No

Failed treatment type

With Local Anaesthesia only With Local Anaesthesia and Nitrous Oxide

Date of last attempt:

Include teeth charting details?

Yes No

Chart

Child Adult

Youth Teeth Charting

Adult Teeth Charting

Adult Teeth Chart

X-Rays request :

X-Ray Included X-Ray Emailed Please Take X-Ray

X-Ray

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

Date

Add more

Referring dentist:

Office email:

Remarks about treatment to be completed:

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

Your referral was sent successfully, thank you!

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Your Moncton Specialist

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