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Stephenson Orthodontics Referring Doctors Form
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Patient's Name
*
Your answer
Parents Name
Your answer
Sex
Male
Female
Clear selection
Phone Number
*
Your answer
Address
Your answer
Business Number
Your answer
Date of Birth
MM
/
DD
/
YYYY
FOR FIRST NATIONS Diand #
Your answer
Has patient been caries free for 6 months?
Yes
No
Clear selection
Is patient’s oral hygiene good?
If NO to either above question, please hold referral until requirement is fulfilled.
Yes
No
Clear selection
Has the patient had a dental exam, cleaning and all restorative treatment completed in the past 12 months?
If NO, please hold referral until work is completed.
Yes
No
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Put # in ONLY if on Family Health Benefits Hosp. #
Your answer
Put # in ONLY if on Social Services Hosp. #
Your answer
Please note any special factors (dental, medical or otherwise) that might be significant in the Orthodontic diagnosis and treatment of the above patient:
Your answer
REFERRED BY DR.
*
Your answer
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