Refer a patient

Reference

Patient’s first name*

Please enter the patient’s first name (3 to 35 characters maximum).

Patient’s last name*

Please enter the patient’s first name (3 to 35 characters maximum).

Gender* You must select its gender.

Date of birth*

Please enter a patient’s date of birth

Relationship to patient* You must select the link with the status.

First name of the person in charge*

Please enter the patient’s first name (3 to 35 characters maximum).

Last name of the person in charge*

Please enter the last name of the person in charge (3 to 45 characters maximum).

First phone*

Type*

Secondary tel.

Type*

Work tel.

Please enter the main phone number (the one that will be easiest to reach you). You must specify whether it is a landline or cell phone. Please enter your secondary phone number. You must specify whether it is a landline or cell phone. Please enter work phone number.

Diagnostics and additional information

CROWNS AND BRIDGES

Complete rehab

Partial rehab

TMJ OCCLUSION / DISORDERS

Signs of excessive pressure on the teeth:

Worn teeth
Fissured, split or fractured teeth
Mobile teeth
Receding gums
Abfractions

Clicking or painful jaw:

Painful TMJ
TMJ that used to click, that no longer click
TMJ pain
Limited opening, locked mouth
Opening deviation

Muscular fatigue and muscle pain:

Muscle fatigue or tense ⁄ painful muscles
Masseter
Temporal
Sterno-cleido-mastoid muscle
Neck

Trauma:

Blow to the jaw

Other symptoms:

Bruxism
Ear pain that does not come from an ear infection
Dizziness or labyrinthitis

Headaches:all types of headaches:

Frontal
Occipital
Temporal
Migraines

You must check at least one of the boxes above. (TMJ OCCLUSION / DISORDERS)

Referents remarks You must provide a text (5 to 180 characters).

Referrer information

Referring*

Please enter the name of the referring dentist or specialist (3 to 35 characters maximum).

Practice No.*

Please enter the Practice Number (3 to 35 characters maximum).

Phone*

Type*

Please enter your phone number. You must specify whether it is a landline or cell phone.

E-mail*

Please enter a valid email address (maximum 84 characters).

Your handwritten signature below.

You must sign here above…

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This form must be completed by a general dentist or other specialist.

This form must be completed by a general dentist or other specialist.

You must check at least one of the boxes above. (TMJ OCCLUSION / DISORDERS)