Referring Healthcare Professionals

Please fill out the form below or click here to download and print a PDF version of the form.

Referring Provider

Referring Office

Office Phone number

PATIENT INFORMATION

Name

Phone Number

Date of Birth

Email

REFERRING FOR

Tongue Frenuloplasty

Upper Lip Frenectomy

Lower Lip Frenectomy

Palatal Expansion

Invisalign

Airway Evaluation

Myofunctional therapy

TMJ Evaluation

Other

CONSULTATION REMARKS

Radiographs emailed to info@myvictoriadentist.ca

Thanks for submitting!

My Victoria Dentist

1070 Douglas Street Suite 220

Victoria, BC V8W 2C4

Phone

Email

Hours

Monday – Thursday: 8:00 AM – 5:00 PM
Friday – Sunday: Closed

Created by

bottom of page