Referral Form

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LONDON, ON

Patient's Date of Birth:

Gender:
FemaleMaleOther/prefer to not say

Does the patient have insurance? YesNo

Private Insurance:
YesNo

Interim Federal Health:
YesNo

Canadian Dental Care Plan (CDCP):
YesNo

Healthy Smiles Ontario (HSO):
YesNo

Private Insurance Details

Insurance Holder's Date of Birth:

Interim Federal Health Details

Canadian Dental Care Plan (CDCP) Details

Healthy Smiles Ontario (HSO) Details

Radiographs and records: YesNo

Date of Radiographs

At Lacombe Sleep Dentistry, we’re more than just a dental practice— we’re a place where your comfort and care come first.