Dental Specialty Group North Toronto North York Kitchener Periodontal
Dental Specialty Group Toronto North York Dentist
Dental Specialty Group North Toronto North York Kitchener Periodontal

To download a pdf referral pad,

Or submit an online referral with the form below.

KITCHENER ONLINE REFERRAL FORM

Ontario Health Insurance Plan (OHIP)
For written prescription purpose.
Dental Insurance Benefit Card
For our office to help you submit claim and/or treatment plan to your insurance company for your reimbursement.

Dr. Jim Robertson | D.D.S
Dr. Amar Sabharwal | Periodontist, BDS, MS, Cert. (Periodontics), Cert. (Oral Pathology)
Dr. Sooyoung Kang | Periodontist, HBSc, DDS, MPerio, FRCD(C)
Dr. Katherine Zettle |

Dental Specialty Group Kitchener
815 Weber St E #1
Kitchener, ON N2H 1H5

MM slash DD slash YYYY
Time
:

For Patients requiring general anesthesia:
1. NO FOOD, NO DRINK OR WATER for 8 hours prior to surgery.
2. A responsible adult must accompany patient and stay to provide transportation home.
3. Public Transportation is not an option.
4. No contact lenses.

Select all applicable teeth
RIGHT 1
LEFT 2
RIGHT 4
LEFT 3
Service(s) to be performed:
Contact me personally after exam
Signed:

Book An Appointment

Book online Book

Or call to schedule an appointment.

Referrals

Download a referral sheet or submit an online referral.

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