Pediatric Referral Form

We appreciate your trust and consideration with your patients. To send a referral to our Pediatric Dental Specialists online, please fill out the form below.

This is for Medical/Dental Professionals only

If you are a parent, please phone our office for assistance.

Online Pediatric Referral form

Referral Form

Patient referral by:

Patient Information

First Name*

Last Name*

Age Category

Phone* (to contact the patient with appointment information)

Is the patient aware of this referral?

Describe reason for referral

Patient Information

First Name*

Last Name*

Address*

Phone*

Select PDG Location*

Patient's Concern(s)

Referring Doctor Information

Referring Doctor*

Office Phone*

Office Address*

Email*

Dentist's Concern(s)*

Comments

Patient Information

First Name*

Last Name*

Address*

Phone*

Select PDG Location*
VancouverRichmondDeltaCoquitlam

Patient's Concern(s)


NOTE: If you are a parent, please disregard this section.

 

Referring Doctor Information

Referring Doctor*

Office Phone*

Office Address*

Email*

Dentist's Concern(s)*
PainRestorative Work RequiredMedical ConcernsPrevious Negative ExperienceSpecific ProblemGeneral AnestheticAnxietyX-rays (Panographic)X-rays (Bitewings)X-rays (Periapicals)

Comments

PDF Form

You can download PDF version of the Pediatric Referral Form.

Request an Appointment

CALL US NOW 604-PDG-1000 OR FILL OUT THE FORM BELOW TO REQUEST AN APPOINTMENT

Happy New Year!

Our offices are open again. If you need to contact us, please call 604-PDG-1000 (604-734-1000) or send us an email, and we will reply as soon as possible. Click here to fill out the contact form.

If you or your child is a PDG patient with a dental emergency, please contact our pager at 604-PDG-PAGE, monitored from 8:00 am to 8:00 pm. If you are calling outside of these hours, please call your local hospital.

Thank you and happy new year.