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Referring Dentists
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  - Referral Form

Get In Touch

Patient Services
Referring Dentists
- More Links
  - Contact Us
  - All Services
- Resources
  - Referral Form

Get In Touch

Referral Form

Patient Information

Download PDF Form

Todays Date

DD slash MM slash YYYY

Name(Required)

First Middle Last

Gender

Date Of Birth

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Patient Email

Patient Phone #(Required)

Patient Cell #

Patient Office #

MCP Number

Expiry Date

MM slash DD slash YYYY

Patient is a Minor

Yes

No

Parent or Guardian Name(Required)

First Last

Parent Email

Consent

Yes, patient has consented to electronic communications

Referring Doctor Information

Referred By

First Last

Practice

Email

Telephone Number

Reason for Referral

Choose Area of Referral

Oral and Maxillofacial Surgery

Doctor Selection

No Preference

Let Me Choose

Full-Time Oral and Maxillofacial Surgeons

Dr. Shannon Davis

Dr. Fadhel Gazala

Dr. Rebecca Woodford

Locum Oral and Maxillofacial Surgeons

Dr. Nicholas Ledderhof

Dr. Navraj Singh Sandhu

Dr. Sina Hashemi

Select Surgery

Implants

Orthognathic Surgery

Extractions

Expose & Bond

Pathology

CBCT

Untitled

Other

Choose Doctor (Pathology)

Dr. Firoozeh Samim

Describe Other Surgery

Single

Multiple

Full Arch

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Singleselect

Single

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Multipeselect

Multiple

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Archselect

Full Arch

Area of Concern

Anesthesia

Local Anesthesia

IV Sedation

General Anesthesia

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Areas

18

17

16

15

14

13

12

11

21

22

23

24

25

26

27

28

48

47

46

45

44

43

42

41

31

32

33

34

35

36

37

38

Verify teeth for extraction

Oral Medicine & Oral Pathology

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Rendered SVG

Select Service

Pathology

TMD

Orofacial Pain

Other

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Additional Comments

Oral Radiology

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Select Surgery (Radiology)

Radiographic Interpretation

Doctor Selection (Radiology)

No Preference

Let Me Choose

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Choose Doctor (Radiology)

Catherine Nolet-Lévesque (FRCD(C), MSc, DMD, Dip, ABOMP)

Area of Biopsy

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Biopsy site

Imaging

File

Drop files here or

Max. file size: 100 MB.

Imaging

Emailed

No Imaging

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Appointment type

Date Image Captured

MM slash DD slash YYYY

Comments(Required)

Atlantic Oral Surgery & Dental Implant Centre is a multidisciplinary centre offering high-quality oral and maxillofacial surgery, orofacial pain, oral pathology and oral radiology services to patients living in or near St. John’s, NL. Our specialty team is dedicated to patient care, comfort and the latest treatment options including experts in oral surgery, oral medicine and oral pathology.

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