Referral Sedation Children • Stouffville SMILES Dentistry & Orthodontics

Sedation For Children

Please complete the form as accurately as possible.

Clinician Information

Dentist's Name*

Office's Name*

Office's E-mail*

Office's Phone*

Patient Information

First Name*

Last Name*

Date of Birth*

Parent/Guardian Information

First Name*

Last Name*

E-mail

Phone*

Referral Details

Reason for Referral

Uncooperative / Anxious
Single Visit Dentistry
Strong Gag Reflex
Special Needs / Autism

ODSP / HSO

ODSP
HSO
None

Referral Notes*

Radiographs / Photos

Upload

Family, Cosmetic, Sleep and Implant Dental Clinic in 5710 Main Street Unit #3, Stouffville, Ontario, L4A8A9 serving residents of Stouffville, Ballantrae, Musselman's Lake, Goodwood, Claremont, Uxbridge, Markham, Richmond Hill and the Greater Toronto Area.

CHILDRENIMPLANTSSEDATIONORTHODONTICSFAMILY

Sedation For Children

Clinician Information

Patient Information

Parent/Guardian Information

Referral Details