Dentist Referral

Referred by Doctor

Email Address

Office Name

Phone

Name of Patient

Phone

Date of birth

Patient Email

Special Considerations:

Complete Care including Hygiene

Tongue and Lip Tie

Sedation/Anesthesia

Trauma

Please list any specific concerns for this patient, or any teeth/areas that require treatment

Radiographs

None taken

E-mailed to info@tinyteeth.ca

Uploaded below

Mailed

Sent with Patient

Upload X-Rays

Upload File

Upload supported file (Max 15MB)

Following treatment, a completion letter will be mailed or e-mailed to your practice.

Following treatment, please

Refer the patient back for hygiene/routine care

Continue to see the patient for hygiene/routine care

Ask the patient which they prefer

Thanks for submitting!

Hours

Monday: 8:30 am– 5:00 pm

Tuesday: 8:30 am – 5:00 pm

Wednesday: 8:30 am – 5:00 pm

Thursday: 7:30 am - 5:00 pm

Friday: 8:00 am - 5:00 pm

Contact us

First name*

Last name

Phone*

Email*

Write a message

Call Us
(289)634-1088

Location

1405 Bloor St Unit 201, Courtice ON, L1E 0A1

bottom of page