Referral FormReferral CardPrintable Version Special Concern TMD - Temporomandibular disorder OSA - Obstructive Sleep Apnea Comprehensive Orthodontic treatment Early treatment and growth modification Pediatric Dentistry Dr. Alvaro Salles Dr. Reynaldo Todescan Jr. Dr. Adriana Salles First Available Doctor Patient Information First Name * Last Name * DOB * Address * Postal Code Home Phone Work Phone Cell Email * Referring Doctor Clinic Date Radiographs Mailed With Patient Email None Please call patient for schedule an appointment. Patient will call to schedule appointment. INSTRUCTIONS Send me a report Call me Please bring with you A list of medication being taken or past medical history information. Any Dental insurance forms or information. Your provincial health card. Rescheduling/Cancelling appointments requires 48 hours notice. Insufficient notice may result in a cancellation fee.
