Doctor Referral Form - Orthodontics at the Wireworks in Barrie and Toronto

Offices

Toronto office:
2994 Dufferin St.Toronto, ON M6B 3T3

Barrie office:
4 Checkley St. Suite 301 Barrie, ON L4N 1W1

Select an Office*

If a preference is not indicated, your patient will be scheduled on the first available appointment.

Referring Doctor

Referred by First Name*

Referred by Last Name*

Name of Referring Office

Referring Office

Patient

Patient First Name*

Patient Last Name*

Date of Birth*

Gender

MaleFemaleX

Address

Street Address*

Apartment*

City*

State*

Postal*

Telephone

Residential*

Business

Appointment Booked

YesNo

Patient to callPlease call Patient

Upload Your Radiographs

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If sending multiple x-rays please note the dates of the x-rays in the comments section below.

Comments/Planned restorative or other treatment

Relevant Medical History