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Our Clinic Location

#2-1800 Hyde Park Road
London ON, N6H 0K1

Phone: 519-914-2987
Email: welcome@imaginecd.ca

Fax: 226-667-6473

London’s Friendly Pediatric Dentist

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Refer a Child

Imagine Children’s Dentistry |

London, ON based Pediatric Dentist;

If you have a general question, please ask us here! We look forward to talking to you soon.

Name

Phone

Email Address

Message

We welcome new patients, and are always happy to see returning ones.

We look forward to talking to you soon.

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Email Address

How many children would you like to schedule?

Child Name(s)

Date of Birth(s)

Patient Address

What type of appointment would you like to schedule? Please select all that apply What type of appointment would you like to schedule? Please select all that apply Dental Cleaning/Checkup Treatment for Dental Cavities Referral from a General Dentist Frenectomy/Lip or Tongue Tie Dental Emergency Other

If other, please specify

Is your child currently covered by private insurance or a government funded dentistry program Is your child currently covered by private insurance or a government funded dentistry program Private insurance (ie. Manulife, Sunlife etc.) Healthy Smiles Ontario (HSO) Private Insurance & Healthy Smiles NIHB None Other

If other, please specify

Please list a few dates/times that work with you. We will try our best to accommodate your schedule

Please use this space to inform us of anything else we should know or other information that would be helpful

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Thank you for the referral. We are always happy to work with you.

Please submit this form and email X-rays to xrays@imaginecd.ca

Referring Dentist Name and Office Name

Clinic Email Address

Clinic Phone

Child’s Name

Date of Birth

Gender

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

X-rays X-rays None Taken Emailed to xrays@imaginecd.ca

Dental Insurance Dental Insurance Private Healthy Smiles NIHB None other

Other

Healthy Smiles Account #

Reason For Referral and Dentist's Main Concern

Imagine Children's Dentistry_CMYK-STICKER (1)

Welcome to Imagine Children’s Dentistry!

We are opening soon, and will be starting to book appointments in late January 2022 (TBD). Please sign up for email updates here and, as we get ready to open we will keep you notified.

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