Referral Implants – Stouffville SMILES Dentistry

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LCBO Plaza – Stouffville

(905) 591 5599

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Dental Implants

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Clinician Information

Dentist's Name*

Office's Name*

Office's E-mail*

Office's Phone*

Patient Information

First Name*

Last Name*

Date of Birth*

E-mail

Phone*

Referral Details

Referral Notes*

Adjunctive Procedures(s)

Extraction
Bone Grafting
Dental Implant(s)
Temporary Crowns/Bridges
Temporary Denture / Flipper / Essix
Final Crown/Bridge
Final Implant Supported Denture

Area of Interest

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Radiographs / Photos

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Stouffville SMILES Dentistry

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reception@stouffvillesmiles.ca

5710 Main Street, Stouffville

Office Hours

MONDAY 10 AM – 8 PM

TUESDAY 10 AM – 8 PM

WEDNESDAY 10 AM – 8 PM

THURSDAY 10 AM – 8 PM

FRIDAY 8 AM – 2 PM

SATURDAY 8 AM – 2 PM

© Stouffville SMILES Dentistry 2021