Refer A Patient

Service from the heart is what we’re known for. A dependable, successful pediatric practice doesn’t come out of thin air, it’s the result of professional relationships of colleagues and patients that surround us.

Thank you for You Trusting Us

We have been specializing in pediatric dentistry for over 40 years and look forward to continuing our tradition of great service into the future. 

The trust you’ve placed in us to give your patients the care they need is incredible and we appreciate your recommendations to PDG. We are so honoured to have your support as we continue to build our practice.

Online Referral form

Referral Form

Patient referral by:

Patient Information

Name*

Age Category

Phone* (to contact the patient with appointment information)

Is the patient aware of this referral?*

Describe reason for referral

Patient Information

Name*

Date Of Birth*

Address*

Phone*

Guardian's Name

Email

Referring Doctor Information

Referring Doctor*

Practice Name*

Office Address*

Office Phone*

Email*

Patient referral to:

Notes

Please forward Radiograph prior to appointment

Notes

Please forward Radiograph prior to appointment

PDF Form

You can download PDF version of the Referral Form.

This is for Medical/Dental Professionals only

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

referRAL TO OUR

Pediatric Dental Specialists

REFERRAL TO OUR​

Orthodontic
Specialists

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Our Certified Specialists in Orthodontics will help you determine which treatment option is right for you.

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