Referral Form

Referring Offices Form

01Patient Information

Please enter a valid preferred name.
Please enter a valid last name.
Please enter a valid telephone number.
Referring Doctor (if applicable)

02Dental Information

Tooth Details
Services Requested
Treatment Requests

03Additional Remarks

* Appointment time is reserved for you. Please be aware that 48 hour notice is required to reschedule your appointment to avoid a cancellation fee. All appointments must be confirmed.
Suite 237 - 1338 Fourth Ave, St. Catharines

Monday - Friday: 8am - 5pm

Payment Options

Your consultation appointment will provide you with a predetermination outlining the costs of your upcoming treatment. Payment will be due at the time service is rendered. We accept Visa, Mastercard, Debit, American Express or cash payments. If you have insurance coverage, we can assist you in submitting your claim electronically or provide you with the forms necessary for you to submit independently.

Book a consultation with us today.

Request Appointment