Doctor Referral Formighk22024-07-30T01:21:58+00:00 Offices Toronto office:2994 Dufferin St.Toronto, ON M6B 3T3 Barrie office:4 Checkley St. Suite 301 Barrie, ON L4N 1W1 Select an Office* —Please choose an option—Toronto OfficeBarrie Office Patient Info 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 Radiograph Upload Your Radiographs MailedEmailedComing with PatientPlease Take If sending multiple x-rays please note the dates of the x-rays in the comments section below. Comments Comments/Planned restorative or other treatment Relevant Medical History Instructions A HEALTH CARD OR DRIVER’S LICENSE IS REQUIRED TO RECEIVE ANY PRESCRIPTION FOR PAIN CONTROL. IMPORTANT INSTRUCTIONS FOR PATIENTS HAVING INTRAVENOUS SEDATION OR GENERAL ANAESTHESIA: Do not eat solid foods within six hours of the time of surgery. Clear fluids include black coffee/tea with no milk, Gatorade, juice and water SHOULD BE drank UP TO 2 hours preop. Arrange to be accompanied to the appointment, driven home, and monitored for the remainder of the day by a responsible adult. Take all medication you normally do with a sip of water unless otherwise advised by the doctor. Cannabis should be stopped 12 hours preop. All other drugs including cocaine and heroin must be out of your system 48 hours prior to your surgery. Do not drink alcoholic beverages for 24 hours prior to your surgery. Do not operate a motor vehicle or hazardous equipment for at least 18 hours following surgery. Dress comfortably with a short sleeve shirt or loose-fitting long sleeve shirt. Do not wear contact lenses. There is a strict No Photo policy - this also applies to visitors in the recovery room. Brush teeth and rinse mouth thoroughly prior to surgery. Use lip balm frequently before surgery to avoid cracked lips. Remove any nose, tongue and lip piercings prior to surgery. Give a minimum of 48 hours’ notice of cancellation to avoid cancellation charge.
