Dental Office Referrals

Are you from a dental office looking to refer a patient? Please send us the following information for us to better help with your patient’s needs.
We will contact your office should there be any additional information needed, or questions pertaining to treatment.

Please note that patient information is kept confidential and secure in our database.

Refer A Patient – Intake

Referring Dental Office Name

Dentist Providing Care to Patient

Dental Office Email

Patient's Full Name

Patient's Date of Birth

Patient's Phone Number

Does this patient have coverage through the Canadian Dental Care Program?

Referral Details Important details for referral, including proposed treatment option(s), any extractions or upcoming work required.

Confirmation Confirmation I confirm that the above patient (or their guardian) has given us permission to provide their information to Frontenac Denture Clinic.