RB Oral Surgery Referral Online Form

Referring to:

Dr Randy Berger Dr Meena Bhatti First Available

Date

Referring Doctor Name

Phone

Email

Patient First Name

Last Name

Middle Initial

Date of Birth

Sex

Address (Street Address)

City

Province

Postal Code

Patient Cell Phone

Home Phone

Email

If patient is under 18 - Parent/Guardian Name

Cell

Parent/Guardian Email

Special Considerations

Limited Mobility Blind/Limited Vision Deaf/Limited Hearing Other

Please specify

Is dental coverage through Supplementary Health/Family Health Benefits?

Yes No

If Yes, Health Card Number

Is dental coverage through NIHB/INAC?

Yes No

If yes, Treaty Number

Do you have private dental insurance?

Yes No

If yes, fill out information below:

Primary Insurance Information

Insurance Company

Policy holders name

Policy holders Date of Birth

Group/Policy #

ID/Certificate #

Secondary Insurance

Yes No

Secondary Insurance Information

Insurance Company

Policy holders name

Policy holders Date of Birth

Group/Policy #

ID/Certificate #

Procedures or Consultations Requested

Teeth To Be Treated (Referral selects the teeth)

Referral selects the teeth

Please Verify Teeth to be extracted/of concern

Radiographs

Attached Emailed Mailed None

Files

Add file

Please upload a file

Date of Radiographs

Health History

Attached Emailed None

Files

Add file

Please upload a file

Reason for referral