Referral Form Home Referral Form TOPSMILES Pediatric Dentistry and Othodontics office 1: 246 St Anne’s Rd. Winnipeg , MB R2M 3A4 (431) 317-7777 (431) 305-0901 office 2: 245-3025 Portage Avenue, Winnipeg , MB R3K 2E2 (204) 956-2060 (204) 942-6869 Date of referral Parent / Guardian Name of Patient Home Phone Address Email DOB (Y/M/D) Referring Dentist Mobile Phone Referring Office Select Location 246 St Anne’s Rd. Winnipeg , MB R2M 3A4245-3025 Portage Avenue, Winnipeg , MB R3K 2E2 Select Treatment Pediatric DentistryOrthodontic TreatmentSupport Test 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 completedYesNo Please send me the pat ient back when t reatm ent is completedYesNo
