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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.

      Pediatric Referral Form (Print)

      Request an Appointment

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

      Vancouver
      Richmond
      Delta/Surrey
      Coquitlam
      Vancouver
      Richmond
      Delta/Surrey
      Coquitlam