Referrals We appreciate it! Please fill out the form below, or you can also email or fax a Referral Pad scan or photo to; Fax (250) 590 5754 Email Tap to email Online Dentist Referral Form Location; Location; West Shore (#206 - 1314 Lakepoint Way) Oak Bay / Victoria (#206 - 1964 Fort St) Either / Unknown Patient name Patient email address Patient contact number DOB: yyyy-mm-dd Parent or guardian Gender GenderFemaleMaleNon-binaryUndisclosed Insurance details: Concerns; Concerns; Crowding Deep Overbite Missing Tooth Impacted Tooth Supernumerary Tooth Spacing Openbite Class II Class III Eruption Concern TMD Overjet Crossbite Habit Other Comments: Recent panoramic Radiographs? Recent panoramic Radiographs? No Sending Reffered By Contact number Referral Date: yyyy-mm-dd Refer Patient
