Patient Referral This form is for Uploading XRays/Reports for a Previously Submitted Referral only. If you have a new referral, please return to the previous page, select "Consultation". Please enable JavaScript in your browser to complete this form. - Step 1 of 2Terms of Service and Privacy Policy *Yes, I have read and agree to the above Terms of Service and Privacy Policy.1. This online referral system allows practices to refer patients to our office. 2. All information submitted in this online referral form will be treated by the clinic as part of your confidential patient record. 3. Total privacy and confidentiality is ensured for both the patient and doctor. 4. Patient information will be encrypted by the secure server software (SSL) before it is uploaded to the doctor's database. 5. The personal information submitted is stored at a secure server in encrypted format. All of the patient information collected is protected against unauthorized access. 6. Information collected will not be shared with any third parties. 7. Only the patient's doctor office will have access to their personal data via a secured, proprietary method. 8. Referral information is purged periodically from the server and does not remain in the database indefinitely. 9. The protocol used in this site is compliant with the PIPEDA Policies and Procedures for accepting and viewing patient data records. 10.The user of this site expressly understands and agrees the clinic and the service/hosting provider ("OptiMicro" and its subsidiaries, affiliates, officers, partners and agents) shall not be liable to you for any direct, indirect, incidental special, consequential or exemplary damages, including, but not limited to, damages from loss of profits, goodwill, use, data or other intangible losses resulting from (a) the cost of procurement of substitute services (b) the use or the inability to use the Service (c) unauthorized access to or alteration of your transmission or data (d) Statements or conduct of any third party on the Service or (e) any other matter relating to the Service. This referral is for *ConsultationUpload XRays/Reports for a Previously Submitted ReferralNextReferral DatePatient InformationTitle *Mr.Mrs.Ms.MissDr.Ind.First Name *Last Name *Date of Birth *GenderMaleFemaleXContact Person (if not patient)Social ServicesODSPPhone # *EmailReferring OfficeDoctor *Phone # *Email *Location (if more than one)Reason for ReferralReason for Referral *Dentoalveolar SurgeryPreprosthetic SurgeryBone GraftingReconstructive SurgeryImplantOral PathologyAlveoplastyPost-Surgical Complications (Required! provide details of surgery, follow up treatment, and Rx below)Orthognathic SurgeryExposure of TeethFrenectomyOtherIf your patient is between the ages of 16 and 21 and being referred for the removal of wisdom teeth, there may be an option to have the consultation and surgery at the same appointment. Please check one of the boxes below:Interested in same day surgeryNot interested in same day surgeryImplant SystemStraumannNobel BiocareOral PathologyLesionUlcerCyst/TumorMucocele*Please attach any intraoral photos and/or radiographs in the “Attachment(s)” section below.Clearly explain why a surgical treatment may be necessary (enter 'N/A' if not applicable) *Additional CommentsSpecify teeth/areas to be evaluated? *YesNoTeeth/Areas5554535251Teeth/Areas6162636465 # (multiple / Teeth/Areas191817161514131211Teeth/Areas212223242526272829Teeth/Areas494847464544434241Teeth/Areas313233343536373839Teeth/Areas8584838281Teeth/Areas7172737475Radiographs / Lab Reports / AttachmentsAttachment(s) *Attached with this referralPlease takeUpload Attachments Drag & Drop Files, Choose Files to Upload Date radiographs were taken *Date radiographs were taken (multiple dates)ReportsWould you like a detailed consultation report? *YesNoPatient InformationFirst Name *Last Name *Date of Birth *GenderMaleFemaleXReferring OfficeDoctor *Radiographs / Lab Reports / AttachmentsAttachment(s) for *Referral previously sent onlineSending files requested by CVOSUpload Attachments Drag & Drop Files, Choose Files to Upload Date radiographs were taken *Date radiographs were taken (multiple dates)PreviousSubmit