Sedation Dentistry Referral | Dr. Jonathan Lok

Please note: we do not accept CDCP (Canadian Dental Care Plan) for any dental treatment performed under sedation with Dr. Jonathan Lok.

REFERRED BY:

Dentist Name:

Clinic Name:

Phone Number:

Email:

PATIENT INFORMATION:

Patient Name:

Phone Number:

Email:

Date of Birth:

Month/Day/Year

Referral For:

Please send x-rays to admin@dentistryondundas.com

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