Referring Dentist Name and Office Name

Clinic Email Address

Clinic Phone

Child’s Name

Date of Birth

Gender GenderPrefer to not SayFemaleMale

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