Dental Specialty Group Toronto North York Dentist

To download a pdf referral pad,

Or submit an online referral with the form below.

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. John Gay | B.A.Sc., D.D.S, F.R.C.D.(C)
Dr. Alfred Chu | B.Sc., D.M.D.

4801 Keele Street, Unit 44
North York, ON M3J 3A4

340 College Street, Suite 465
Toronto, ON M5T 3A9

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: