dentistrywhileasleep@rogers.com
(905) 683 3300
279 Kingston Rd E. Unit 1, Ajax, Ontario, L1Z 0K5
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Referring Doctors

Patient Referral Form

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We appreciate the confidence you show in us by referring your patient to our practice. Please use the form below to provide us with the Patient Information of whom you are referring.

Alternatively, you can download and fill out our Patient Referral form. After you have completed the form, please fax (905-683-3363) or e-mail (dentistrywhileasleep@rogers.com) it back to the office.

Thank you for the kind referral.

Referring Doctor/Dentist

Doctor's Name*


Doctor's Telephone Number*


Doctor's Fax Number


Doctor's Email Address*

Doctor's Address*

Patient Information

Patient's Name*


Date of Birth:


Address

Email Address*

Cell Phone*

Phone Number:*

Significant Medical Concerns:

Reason for Referral:*

TMJ
Sleep Apnea
Orthodontics
General Dentistry
Other:

Are there X-Rays Available?

Yes   |   No

Please send X-Rays to dentistrywhileasleep@rogers.com

We thank you for your referral and will contact your office to confirm intake. If there is anything we can do to serve you better, please let us know.