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.

NORTH YORK 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.
Dr. Garry Toor | D.D.S, F.R.C.D.(C)
Dr. Anthony Chung | D.D.S, D.I.P., ENDO, F.R.C.D.(C)

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

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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