Online Self-Referral Patient Form

Please complete this form to refer yourself or submit a referral on behalf of someone else

Patient Details

First Name *

Last Name *

Patient Date of Birth *

Patient Contact Number *

Patient Email Address

Patient Address *

Street Address *

City *

State / Province *

Postal / Zip Code *

Patient Consent Information

Who makes your healthcare decisions? *

SelfLegal guardianSubstitute decision maker

Please state the name of your legal guardian or substitute decision maker

First name *

Last name *

Please state their relationship to you? *Legal guardian, parent, sibling, friend

Please provide your legal guardian's or substitute decision maker's phone number *

Please provide your legal guardian's or substitute decision maker's email address

Reason for Referral *(e.g., any information that you think would be important for us to know and/or impact your dental care)

Medical History *(e.g., medical conditions, medications, allergies)

Dental History *(e.g., your previous dentist information, your dental records)

Other relevant information(e.g., wheelchair access)

Please upload relevant files

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(e.g., written referral, medical summary, dental records including dental radiographs etc.)