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Online Doctor Referral Form 2018-01-24T17:32:28+00:00

Fredericton Oral Surgery
123 York St, Suite 200
Fredericton, NB E3B 3N6

T: 506-458-8864
F: 506-450-0313

Doctor Referral Form

Please select a doctor :   Dr. Martin BelangerDr. Nach DanielDr. Karim Al-Khatib
Today's date
Patient Name
Parent/Guardian
Date of Birth
Telephone Number
Address
Please select one (if this is applicable to your patient)
Dental InsuranceIndian AffairsSocial Assistance
Type of treatment :
ExtractionExposureTMJApical SurgeryPathologyImplantologyJaw SurgeryPreprosthetic Surgery
Adult Teeth Charting
Please select one or more of the following as this example :
Upper Right Side 1817161514131211 2122232425262728 Upper Left Side
Lower Right Side 4847464544434241 3132333435363738 Lower Left Side
Youth Teeth Charting:
Please select one or more of the following as this example :
Upper Right Side 5554535251 6162636465 Upper Left Side
Lower Right Side : 8584838281 7172737475 Lower Left Side

X-Rays request :
X-Ray IncludedX-Ray EmailedPlease Take X-Ray

Referring dentist :
Remarks