Referring Dentist Name and Office Name

Clinic Email Address

Clinic Phone

Child’s Full Name

Date of Birth

Gender GenderPrefer to not SayFemaleMale

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

Parent/Guardian Name 2

Parent/Guardian Phone 2

Parent/Guardian Email 2

X-rays: please include all taken within 6 months X-rays: please include all taken within 6 months None Taken Emailed to xrays@imaginecd.ca

Dental Insurance Dental Insurance Private Canadian Dental Care Plan (CDCP) NIHB Healthy Smiles IFHP None other

Other

Healthy Smiles Account #

CDCP_Policy_Number

NIHB_Policy_Number

IFHP Policy #

Reason For Referral and Dentist's Main Concern