Referral Form

TOPSMILES

Date of referral

Parent / Guardian

Name of Patient

Home Phone

Address

DOB (Y/M/D)

Referring Dentist

Mobile Phone

Referring Office

Select Location

Select Treatment

Pediatric DentistryDr. Adriana Salles FRCD (C)Dr. Hamideh Alai-Towfigh FRCD(C)First available

Orthodontic Treatment Dr. Alvaro Salles FRCD(C)

This is a referral regarding:Pain/ SwellingGeneral AnaestheticEmergencySedation with nitrous oxideOther

Please evaluate for:Comprehensive Orthodontic TreatmentEarly Treatment / Modification

Comments:

Please call the parent/ guardian to arrange appointment YesNo

We are sending the most current radiographsYesNo

Please inform us of tr eatment completed YesNo

Please send me the pat ient back when t reatm ent is completedYesNo

246 St Anne’s Rd.
Winnipeg , MB R2M 3A4

245-3025 Portage Avenue,
Winnipeg , MB R3K 2E2

Monday – Friday
08:30 AM – 04:30 PM
Saturday
09:00 AM – 03:00 PM
Sunday
Closed