Form | Refer a patient

Form for dentists.

    Patient information:

    Please call patientPatient will call

    Reason for referral:
    CrowdingExcess spaceMissing teethImpacted teethCrossbiteOral habitsOverjetClass IIClasse IIIOverbitePre-prosthodontic orthoOrthognathic surgery


    Imaging (radiographs, photos) | Formats .jpg, .pdf, .txt:

    Date of radiograph:

    Name of referring dentist:

    Email of referring dentist:

    Additional information:


    If you have any questions about our clinic, please contact us and we will be happy to assist you.

    10 Allée de Hambourg, Suite 305B Gatineau (Québec) J9J 4K1
    Opening Hours

    All rights reserved © 2022

    All rights reserved © 2022