Referral Form

For Referring Offices

Refer A Patient

Our team aims to be an extension of your office. We support clear consultation, patient education, surgical care, and diligent post-operative communication.

• Submit referral information securely
• Include relevant radiographs when available
• Share medical concerns that may affect care
• Contact us if the case is urgent

For Referring Offices

Patient And Insurance Details

The referral form asks for patient name, date of birth, gender, address, responsible party details, contact telephone, email address, preferred doctor, and insurance status.

• No insurance
• Private insurance
• CDCP
• ODSP
• HS
• OW

For Referring Offices

Referring Doctor Information

Referring offices can include the doctor's first and last name, telephone number, email address, and clinical comments so the Waterloo oral surgery team can coordinate care clearly.

For Referring Offices

Procedures And Tooth Chart

The form includes procedure selections and tooth chart details so referrals are easier to triage and prepare for consultation.

• Implants
• Pre-prosthetic surgery
• Ridge augmentation
• Oral or facial lesion
• Bone grafting
• Extraction
• Alveoplasty
• Biopsy
• Exposure or expose and bond
• Frenectomy
• Apicoectomy
• Infection or incision and drainage
• Hard tissue or soft tissue concerns
• Other procedure details

For Referring Offices

Radiographs And Clinical Photos

Referring offices can indicate whether radiographs are being emailed, given to the patient, requested from our office, or not available. After submitting the referral, offices can upload X-rays or clinical photos when needed.

• Accepted file types include jpg, jpeg, png, and pdf
• Maximum file size is 50 MB
• Up to 10 files may be uploaded
• Include the date X-rays were taken when available

For Referring Offices

Communication With Your Office

After patient care is completed, referring offices can expect communication about recommendations or treatment provided.