Winnipeg Dental Implants-Patient Referral Form

Winnipeg Dental Implants - Patient Referral Form

Patient Referral Form

Ernest C Cholakis, DMD, MBA General Dentist. Practice limited to: Prosthodontic and Implant Dentistry. Please call our office at 204-488-4564 or use the quick patient referral form below. Welcoming all referrals.

Patient First Name: *
Patient Last Name: *
Pateint Date of Birth:
Patient Address:
City:
Postal Code:
Province:
Patient Contact Phone: *
Patient Email:
Fixed Prosthodontics:	Crowns
	Bridge
	Partial
	Full
	Reconstruction
	Veneers
Dental Implants:	Single Tooth
	Multiple Teeth Implants
	C.T. guided surgery
	Teeth in a day
	Implant Supported Dentures
Implant Placement only:	Yes - Implant placement only
	No - Implant placement only
Implant Systems:	Ankylos
	Nobel Replace Select
	No preference
Available records to send:	Radiographs
	PA/BW
	PAN
	Diagnostic Casts
	Photographs
	Probings
	FMS
	Other
Consultation re: Treatment (please provide urgency or areas of concern)
Relevant medical history/details of clinical problem:
	Please call the patient
	Patient will call
	Radiographs enclosed/sending
	Please return radiographs after use
An appointment has been made on:
Referring Dentist name:
Clinic:
Address:
Postal code:
Telephone: *
Clinic / Doctor Email:

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