Division of Dentistry REFERRAL FORM 401 Smyth Road Web site: www.cheo.ca Fax: (613) 738-4201

Ottawa, ON K1H 8L1 Telephone: (613) 737-2357

REFERRING PROFESSIONAL

Name: ____________________________________ Fax:________________________________

M.D. DDS/DMD Telephone:____________________________

Mailing Address:____________________________ Signature:_____________________________

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PATIENT INFORMATION DOB ________________ Sex: M F Year Month Day

Patient Name: print exactly as on Health Card Parent/Guardian Name(s):

First Name: _______________________________ _____________________________________

Surname: _________________________________ ____________________________________________

Home Address: ____________________________ Telephone:

______________________Postal Code _________ Home:_______________________________

Health Card No. ________________Version _____ Work (Mom):_________________________

Will an interpreter be required? Work (Dad): __________________________

No Yes Language __________________

Other: _______________________________

REFERRAL INFORMATION Dental Insurance: ____________________ Reason(s) for referral. Please provide relevant history and findings

_________________________________________________________________________________________

_________________________________________________________________________________________

MEDICAL INFORMATION

_________________________________________________________________________________________

_________________________________________________________________________________________

Current (< 6 months old) radiographs are requested: Clinic/Service Required

Radiographs enclosed? Yes Type _________________ Dental EMERGENCY Yes No

No Reason: to follow by mail Specialty ___________________________

will bring to appointment

unable to obtain, family aware that they MOH Dental Program Funding Assessment

may be taken at appointment (Eligible diagnosis must be noted above)

Upon acceptance of referral: WE WILL CONTACT THE PATIENT/FAMILY TO BOOK APPOINTMENT and will notify

referring professional WITHIN 10 BUSINESS DAYS. Please instruct families NOT to call the clinic before this time.