Dental Referral Form Template Word

The Dental Referral Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. These templates are fully editable and printable, providing you with flexibility to tailor them to your needs.

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Sample

Dental Referral Form Template Word – Canada

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1. Referring Dentist Information

2. Patient Information

3. Reason for Referral

4. Patient Medical History

5. Current Dental Issues

6. Medications

7. Attachments

(Please attach any relevant x-rays, clinical notes, or other supportive documents.)

8. Preferred Method of Contact
Email
Phone

9. Signature and Consent

I confirm that the information provided is accurate and I consent to the referral of the patient.

Date:

Referring Dentist’s Signature:

PDF

WORD

Examples

Dental Referral Form Template – Canada (1)

Patient Information:
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]

Referring Dentist Information:
[Referring Dentist’s Name]
[Referring Dentist’s License Number]
[Referring Dentist’s Practice Name]
[Referring Dentist’s Address]
[Referring Dentist’s Phone]
[Referring Dentist’s Email]

Reason for Referral:
[Detailed description of the patient’s condition and the specific reasons for referral, e.g., “The patient has been experiencing severe tooth pain and requires an endodontic evaluation for potential root canal treatment.”]

Medical History:
[Relevant medical history, including allergies, medications, and any previous dental treatments that may impact the patient’s care.]

Diagnostic Information:
[Include any relevant diagnostic imaging or test results, e.g., X-rays, CT scans, or other assessments.]

Preferred Contact Method:
[Phone/Email/Postal Mail – specify preferred contact method for follow-up and coordination.]

Signature:
[Referring Dentist’s Signature]
[Date]

Dental Referral Form Template – Canada (2)

Patient Information:
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]

Reason for Referral:
[A clear, concise description of the dental issue prompting the referral, e.g., “The patient presents with advanced periodontal disease and requires a comprehensive evaluation and management plan.”]

Medical History:
[Summary of the patient’s health history relevant to dental care, including pre-existing conditions and any medications that may affect treatment.]

Existing Treatments:
[Details of any treatments currently received by the patient, including ongoing dental procedures or specialist consultations.]

Urgency of Referral:
[Indicate if the referral is urgent or routine, along with justification for urgency if necessary.]

Preferred Contact Method:
[Specify the preferred way to communicate regarding the patient’s progress or additional questions.]

Signature:
[Referring Dentist’s Signature]
[Date]

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Dental Referral Form Template Word - Canada